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Atonia  Gastrica 

{jihdominal  Relaxation) 


ACHILLES  ROSE.  M.D. 

and 

ROBERT  COLEMAN  KEMP.  M.D. 


FUNK  &  WAGNALL^  COMPANY 

NEW  YORK  AND  LONDON 
1905 


Copyright,  1905, 

By 

FUNK   &   WAGNALLS   COMPANY 

[Printed  in  the  United  States  of  America] 

Putthcd  April.  1905 


PREFACE 

The  object  of  this  book  is  to  present  facts 
which  demonstrate  the  relations  of  abdominal 
relaxation  to  a  number  of  pathological  condi- 
tions, and  to  show  the  importance  of  these  re- 
lations in  regard  to  the  etiology,  pathology,  and 
therapy  of  diseases  of  the  stomach,  the  abdomi- 
nal organs  in  general,  the  organs  of  respiration, 
of  circulation,  and  the  nervous  system. 

A  new  phase  in  the  study  of  diseases  of  the 
stomach  presented  itself  when  the  significance 
of  the  splashing  sound  was  interpreted,  and  the 
results  obtained  by  the  method  of  relieving 
atonia  gastrica  by  means  of  an  adhesive  plaster 
belt  have  been  in  many  respects  remarkable. 

This  belt  is  something  more  than  such  a 
support  as  is  given  by  an  ordinary  abdominal 
supporter  or  bandage,  for  it  exerts  an  effect  on 
circulation  and  innervation  which  can  only  be 

[V] 


PREFACE 

compared  to  that  of  a  plaster-of-Paris  dressing 
in  cases  of  fracture  or  arthritis. 

It  is  an  established  fact  now  that  not  only 
anomalous  motoric  functions,  but  also  secretory 
disorders  of  the  stomach  may  be  corrected  by 
this  simple  means.  By  its  effect  on  circulation 
and  innervation  it  will  relieve  dysmenorrhea 
and  pain  in  cases  of  cholelithiasis. 

During  the  short  time  the  method  has  been 
adopted  a  number  of  indications  for  its  employ- 
ment have  been  discovered,  and  many  more  will 
be  found  by  further  obser\^ations,  for  there  can 
be  no  doubt  that  it  is  most  important  to  restore 
the  tonus  of  the  abdominal  muscles  in  many 
gynecological  affections,  especially  in  cases  of 
uterine  hemorrhage,  and  for  this  purpose  no  bet- 
ter means  can  be  imagined  than  the  abdominal 
belt  of  adhesive  plaster. 

Again,  the  early  treatment  of  gastroptosia  by 
means  of  this  belt  may  prove  a  prophylactic 
against  the  occurrence  of  different  forms  of  ab- 
dominal or  inguinal  hernia,  as  it  is  certainly  a 
most  rational  prophylactic  against  the  forma- 
tion of  gall-stones. 

[vi] 


PREFACE 

For  theoretical  reasons  it  suggests  itself  as  a 
prophylactic  against  perityphlitis,  barbarously 
called  by  a  horrible  name. 

Certain  observations,  not  completed  yet,  point 
to  its  usefulness  in  some  cases  of  acne  rosacea 
and  also  of  tachycardia. 

Our  medical  onomatology  is  to  a  great  ex- 
tent corrupt,  illiterate,  ridiculous,  absurd;  and 
this  condition  has  caused  confusion,  as  we  no- 
tice in  the  case  of  the  wrong  interpretation  of 
the  simple  word  atonia. 

Well  has  Adamantios  Korais  said : 

NopLil^u)  OTt  ij  8t.a<pdopa  77^9  YX<ti(Tff-q<i  elvai  ffo/ysvijg 
vdffo^  T^p  8ia<pdopa^  rwv  rjOwv  y.ai  xara  tou<i  ''hnoxpari- 
xoh<s  xavova^  l^rj'sT  xai  ffuyyevr/  xac  irapofMOcav  depa- 
iieiav.* 

With  the  introduction  of  more  and  more  new 
compounds,  more  and  more  irregularities  came 
into  our  onomatology,  because,  so  long  as  Greek 
was  considered  a  dead  language,  no  exact  rules 
could  be  formulated  to  control   the  formation 

*  I  consider  that  the  corruption  of  language  is  a  disease 
closely  allied  to  corruption  of  manners  and  demands  also, 
according  to  the  Hippocratic  canons,  a  similar  course  of 
curative  treatment- 

,     [vii] 


PREFACE 

of  the  new  compounds  which  have  to  be  con- 
structed. In  the  case  of  Latin  there  exists  no 
authority,  that  is,  no  people,  who  can  decide 
whether  a  new  Latin  compound  is  correct ;  and 
in  the  case  of  Greek,  the  Greeks  who  really 
could  decide  have  not  been  and,  as  yet,  are  not 
considered.  The  Greeks  do  not  adopt,  with  the 
constantly  imported  foreign  ideas,  the  connota- 
tive  words  also  of  foreign  peoples.  They  refuse 
to  have  a  hybrid  language.  Their  history,  their 
national  pride,  lead  them  to  exclude  foreign 
words,  and  to  take  only  such  necessary  ele- 
ments from  the  ancient  Greek  as  enable  them 
to  create  new  symbols  for  new  ideas.  When 
constructions  and  forms  have  been  remodeled 
after  the  old  Greek,  incorrect  elements,  when 
discovered,  are  extirpated  with  ever-increasing 
strictness  and  tact.  Before  a  new  formation  is 
introduced  into  the  regular  language  it  has  to 
stand  a  severe  test  and  criticism.  Nothing  will 
be  accepted  and  grafted  into  the  regular  lan- 
guage which  deviates  in  any  way  from  the  ge- 
nius of  the  Attic  tongue. 

Comparing  the  active  measures  taken  by  the 

[viii] 


PREFACE 

Greeks  against  the  corruption  of  their  language 
with  the  wanton  barbarisms  of  our  nomencla- 
tors,  we  are  forced  to  the  conclusion  that  the 
only  way  to  purify  our  onomatology  is  to  con- 
sult our  Greek  colleagues  of  the  University  of 
Athens.  We  need  not  fear  that  any  terms  rec- 
ommended by  them  will  be  contrary  to  the 
spirit  and  form  of  classical  Attic. 

The  Greek  of  to-day,  as  taught  in  the  schools 
throughout  Greece,  and  employed  as  the  official 
language  of  the  Government  of  Greece,  is  pura 
Attic,  as  pure  as  ever  was.  It  is  the  immortal 
Greek  in  all  its  youth  and  beauty,  free  from 
foreign  elements. 

It  is  necessary  to  emphasize  this  fact  because 
our  college  professors,  with  the  rare  exception 
of  some  excellent  college  men  and  colleges  in 
America,  are  bound,  as  in  a  conspiracy,  to  sup- 
press this  truth ;  and  this  conspiracy  indeed  is 
the  cause  of  our  corrupt  onomatology. 


[ix] 


CONTENTS 


Acid 


Preface      

i.  ox  the   slgxificanxe  of  the  splashing 

Sound  of  the  Stomach,  . 
II.  Methods  for   Locating  the    Position  of 
THE  Stomach, 
Methods  of  Examination, 
Inspection, 

Palpation  of  the  Stomach, 
Percussion  of  the  Stomach 
Auscultatory  Percussion,  . 

Flicking 

Inflation  of  the  Stomach  with   Carbonic 
Gas,     ...... 

Inflation  of  the  Stomach  with  Air,  . 
Inflation  of  the  Stomach  with  Water, 
Translumination  of  the  Stomach, 
The  Circumscribing  Gastrodiaphane, 
X-Ray, 

III.  Atonia  Gastrica  and  a  New  Method  of 

Treatment, 
Cardiac  Indications, 
Pulmonary-  Indications,     . 
Gastro-intestinal  Indications, 
Pelvic  Indications,    .         . 

IV.  Floating  Kidney,    . 
V.  Type  of  Adhesh-e  Plaster 

dominal  Belt, 
VI.  History  and  Literature, 
[xi] 


for  the  Ab 


23 
28 
29 

31 

32 

34 

36 

36 
38 
39 
44 
46 

54 

64 
III 
112 

"3 
116 

152 

16S 
174 


ILLUSTRATIONS 


PAGE 

Normal  Position  of  the  Stomach,       .        .        .        .26 

Ptosis, 26 

The  Kemp  Tube, 29 

Kemp's  Stomach  Whistle,  .         .        .        .        ,42 

Einhorn's  Gastrodiaphane, 45 

Circumscribing  Gastrodiaphane,         .  .48 

A  Normal  Stomach,  the  Dilated  Organ,  and  Several 

Degrees  of  Gastroptosia, 55 

The  Radiodiaphane  (Einhorn),  .         .         .        -57 

The  Plaster  Bandage, 86 

Applications  of  the  Plaster  Bandage,  following    88 

Rosewater's  Abdominal  Plaster  Strapping,       facing  102 
Curves:  Migraine,         .         .        .  134,  135,  136,  137,  138 


ATONIA  GASTRICA 


ATONIA  GASTRICA 


I 

ON     THE      SIGNIFICANCE      OF     THE 

SPLASHING   SOUND   OF   THE 

STOMACH 

The  splashing  sounds  of  the  stomach  are  pro- 
duced when  water  and  air  are  agitated  together, 
when  either  the  whole  body  or  the  stomach 
alone  is  shaken.  The  latter  is  done  when  we 
tap  with  the  fingers  on  the  relaxed  abdominal 
walls  over  the  stomach.  To  obtain  the  splash- 
ing sound  by  means  of  such  tapping  the  pa- 
tient must  be  in  the  recumbent  position.  The 
sound,  however,  can  also  be  produced  by  sha- 
king the  whole  body  while  the  patient  stands 
upright. 

The  phenomenon  in  question  can  be  elicited 
in  many  people  of  ordinary  good  health  shortly 
after  they  have  taken  liquids  or  fluid  food.  But, 
[I] 


ATONIA   GASTRICA 


notwithstanding  the  ordinary  good  health,  a 
stomach  from  which  this  splashing  sound  can 
be  produced  is  not  in  normal  condition ;  for  in 
normal  condition  we  can  not,  even  at  the  height 
of  digestion,  elicit  a  splashing  sound,  because 
the  stomach  closes  concentrically  about  its  con- 
tents, the  organ  being  adapted  to  the  volume 
of  the  ingesta.  This  peristole  exists  as  long  as 
the  reflectory  tonus  of  the  gastric  muscles  re- 
mains intact. 

Wherever  we  can  elicit  this  splashing  sound, 
we  have  before  us  relaxation  or  atony  of  the 
stomach. 

In  regard  to  those  peculiar  splashing,  gur- 
gling, or  croaking  noises  of  the  stomach  which 
some  persons  can  develop  by  means  of  abdomi- 
nal pressure,  and  which  excite  the  attention  of 
laymen,  and  even  of  some  physicians,  Kussmaul 
says :  "  There  are  many  persons,  whose  stom- 
achs are  either  of  normal  dimensions  or  dilated, 
who  have  attained  great  skill  in  causing  such 
noises.  By  means  of  their  abdominal  muscles 
they  make  a  horrid  music  with  every  contrac- 
tion or  expansion  of  the  abdominal  wall,  a  music 

[2] 


SPLASHING   SOUND   OF   STOMACH 

which  can  be  heard  at  some  distance.  It  is  a 
cooing,  croaking,  belching  sound,  and  receives 
the  most  fantastic  explanations;  the  presence 
of  live  frogs  in  the  stomach  and  the  like  is 
sometimes  thought  of.  In  hypochondriacs  it 
gives  rise  to  somber  imaginations,  and  hysteri- 
cal persons  take  advantage  of  it  to  create  a  sen- 
sation or  admiration  by  such  ventriloquism. " 

Baradat  de  Lacaze,*  on  examining  patients 
from  different  wards  who  did  not  suffer  from 
gastric  disorders,  found  that  he  could  produce  the 
splashing  sound  regularly  for  two  hours  after 
liquid  food  had  been  ingested,  and  for  six  hours 
after  full  meals  composed  of  both  liquid  and 
solid  food.  As  we  shall  see  presently,  my  own 
observations,  made  on  a  hundred  patients,  do 
not  correspond  with  the  results  obtained  by 
this  author. 

Oser  f  observed  that  in  cases  of  gastric  atony 
the  fluctuation  of  small  waves  could  be  elicited 
for  four  or  five  hours  after  a  full  meal,  and  Bar- 

*"fitude  sur  le  bruit  de  clapotage."  Th^se  de  Paris, 
1884. 

f  "Die  Ursachen  der  Magenerweiterung,"  Wiener 
Klinik,  1881. 

[3] 


ATONIA  GASTRICA 


adat  de  Lacaze  stated  that  the  splashing  sound 
could  be  produced  for  two  hours  after  small 
meals,  and  as  long  as  six  or  seven  hours  after 
full  meals,  in  all  cases  in  which  the  passage  of 
food  from  the  stomach  was  retarded. 

Malibran  questions  whether  this  symptom  is 
necessarily  pathological;  still,  he  admits  its 
significance  if  it  continues  under  certain  con- 
ditions. 

The  same  author  remarks  that  during  infancy 
the  splashing  sound  can  be  produced  in  the 
large  intestine  if  distended  by  gas ;  that  it  can 
not  be  exactly  localized  by  the  ear  in  cases  of 
infants.  He  denies  that  the  splashing  sound  of 
the  stomach  and  the  gurgling  noise  of  the  intes- 
tine in  infants  can  be  distinguished  with  cer- 
tainty. He  also  reports  six  cases  in  which  the 
autopsy  had  shown  the  possibility  of  error  in 
this  regard.  In  these  six  cases  the  splashing 
sound  had  been  produced  during  life  in  the 
colon  half  filled  with  semi-liquid  fecal  matter. 

When  the  new  methods  of  examination  of  the 
stomach  were  first  introduced,  it  was  assumed 
that  the  splashing  sound  elicited  below  the  um- 
[4] 


SPLASHING  SOUND   OF   STOMACH 

bilicus  in  dyspeptic  persons  meant  dilatation  of 
the  stomach.     And  this  was  correct. 

By  the  term  dilatation  of  the  stomach,  ectasis 
ventriculi,  most  authors  at  present  understand  a 
typical  condition  in  which  the  food  stagnates 
in  the  stomach,  in  which  the  ingesta  taken  the 
day  previously,  or  before,  are  found  on  washing 
out  the  stomach  in  the  morning. 

Einhorn  *  has  enumerated  the  terms  used  by 
different  authors  to  designate  a  pathological 
condition  of  the  stomach  which  not  only  com- 
prises an  anatomical  feature,  as  the  word  dila- 
tation implies,  but  which  is  characterized  by  a 
much  more  important  lesion  of  the  mechanical 
functions  of  that  organ.  These  terms  are : 
"dilatation  of  the  stomach,"  "anatomical  and 
clinical  dilatation  of  the  stomach,"  "'ectasis^ 
ventriculi,''  "insufficiency  of  the  stomach," 
"gastric  insufficiency  of  the  first  and  second 
degree."  He  himself  uses  the  word  "  ischo- 
chymia  "  (jV/sjv,  to  retain,  and  yuiio^,  chyme)  for 

*"  Diagnosis   and  Treatment  of  Stenosis  of  the  Py- 
lorus."   Medical  Record,  January  19,  1895. 
t  Ectasia  is  ungrammatical.     The  word  is  ectasis. 

[5] 


ATONIA   GASTRICA 


a  prolonged  stagnation  of  chyme  in  the  stom- 
ach, to  designate  a  complex  of  symptoms  with- 
out stating  the  cause. 

Since  we,  for  clinical  purposes,  distinguish 
between  dilatation  and  atony  of  the  stomach, 
the  phenomenon  of  this  splashing  sound  alone 
does  not  suffice  to  indicate  dilatation,  or  atony 
as  clinically  understood.  It  is,  however,  im- 
portant for  determining  the  lower  border  of  the 
stomach,  the  low  position  of  the  organ  when 
exceptional  causes,  such  as  tumors,  can  be  ex- 
cluded. It  is  of  diagnostic  importance,  as  it  in- 
dicates relaxation  of  the  muscles  of  the  stomach 
in  cases  in  which  it  can  be  easily  produced  over 
a  large  area.  If  found  while  the  stomach  is 
free  of  food  it  is,  except  in  instances  of  contin- 
uous supersecretion,  a  means  of  diagnosticating 
ectasis  gastrica. 

Moreover,  atonia  gastrica,  gastroptosia,  and 
dilatation  of  the  stomach  are  identical,  and  if 
we  keep  this  fact  in  view  we  shall  succeed  in 
doing  away  with  the  tobu  waboJm  in  the  wri- 
tings of  many  authors  in  regard  to  these  terms. 

Relaxation  of  the  muscles  of  the  stomach 
[6] 


SPLASHING   SOUND   OF   STOMACH 

means  that  the  stomach  does  not  contract 
around  its  contents,  that  the  muscles  follow  the 
pressure,  i.e.,  the  weight  of  the  ingesta,  and 
this  is  gastroptosia. 

Relaxation  of  the  fibers  of  the  muscles  means 
elongation  of  the  fibers,  and  therefore  dilatation 
of  the  stomach. 

Kemp's  distinction  between  gastroptosia  and 
dilatation  of  the  stomach  is  as  follows :  In  dila- 
tation the  lesser  curvature  retains  its  relation 
to  the  diaphragm.  The  distance  between  the 
lesser  and  the  greater  curvature  is  increased, 
but  the  lesser  curvature  still  maintains  its  rela- 
tion to  the  diaphragm,  with  the  exception  that 
the  pyloric  end  may  extend  farther  over  and 
somewhat  farther  down ;  but,  in  the  main,  this 
rule  holds  good,  and  it  can  be  looked  upon  as 
a  differential  point  between  gastroptosia  and 
stomach  dilatation. 

Kemp  is  quite  correct.  Gastroptosia  is  a 
lowered  position  of  the  pylorus  and  of  the  lesser 
curvature.  The  definition  of  the  lower  border 
of  the  stomach  alone  is  not  diagnostic,  since 
this  may  be  merely  the  characteristic  symptom 
[7] 


ATONIA   GASTRICA 


of  a  large  stomach.  When  we  have  to  distin- 
guish between  ectasis  and  ptosis,  we  must  know 
the  position  of  the  lesser  curvature;  without 
such  knowledge,  neither  a  general  increase  of 
volume,  nor  an  abnormally  lower  position  of  the 
stomach,  nor  a  combination  of  both,  can  be  di- 
agnosticated. Gastroptosia  can  best  be  diag- 
nosticated by  means  of  Kemp's  circumscribing 
gastrodiaphane. 

Kussmaul  was  the  first  who  called  attention 
to  the  descent  and  the  vertical  position,  as  well 
as  to  the  loop  form  of  the  stomach. 

A  complete  descent  of  the  entire  stomach  is 
not  possible,  since  the  cardiac  orifice  can  not 
change  its  position  in  the  region  of  the  twelfth 
thoracic  rib. 

The  word  atonia  is  the  pure  Greek  arovia,  and 
means  relaxation.  It  does  not  mean  motor  in- 
sufficiency, as  some  will  have  it. 

Stiller  uses  the  word  atonia  in  its  proper 
meaning.  Eisner  says  :  "  What  immense  con- 
fusion will  happen  if  the  generally  adopted  un- 
derstanding that  atonia  gastrica  is  motor  insuf- 
ficiency of  the  muscles  of  the  stomach  shall  be 
f8] 


SPLASHING   SOUND   OF   STOMACH 

abandoned."  We  shall  see  how,  on  the  con- 
trary, great  confusion  will  be  cleared  up  by  call- 
ing the  thing  by  its  right  name. 

Some  author  says  :  "  The  descriptions  in  the 
books  of  the  symptoms  of  gastroptosis  "  (the 
correct  word  is  gastroptosia)  "  are  hopelessly 
obscure  and  chaotic,  characteristic  and  diagnos- 
tic points  are  few,  and  these  few  misleading. " 
To  this  I  wish  to  say  that  the  symptoms  in  gas- 
troptosia are  manifold  and  numerous,  but  if  we 
keep  in  view  that  there  is  only  one  factor,  and 
that  factor  is  relaxation,  we  have  a  characteris- 
tic point,  and  one  which  is  not  misleading,  but 
indicates  at  once  a  rational  method  of  treat- 
ment, which  in  most,  if  not  in  all,  cases  will 
cause  the  symptoms  to  disappear  or  become 
modified.  How  all  the  difficulty,  the  hopelessly 
obscure  chaos  of  which  the  author  in  question 
complains  has  been  brought  into  the  medical 
world,  like  many  other  similar  conditions,  solely 
by  our  unscientific,  misleading  onomatothesia, 
the  readers  may  judge  for  themselves. 

Ewald,  after  describing  the  symptoms  which 
are  produced  by  stagnation  of  the  contents  of  the 
[9] 


ATONIA   GASTRICA 


stomach,  says  :  "  In  such  cases  we  have  to  deal 
with  motor  insufficiency,  or,  as  some  older  writers 
call  it,  atony  of  the  stomach,  which  in  general, 
however,  causes  less  intense  symptoms — altho 
they  may  become  intensified  in  some  cases." 

Boas  asserts  that  atonia  gastrica,  myasthenia 
gastrica,  and  mechanical  insufficiency  have  been 
employed  as  synonyms,  and  gives  the  following 
definition  :  "  By  atony  of  the  stomach  is  under- 
stood the  inability  of  the  organ  to  propel  the 
chyme  into  the  intestine  within  the  legitimate 
time."  He  proposes  the  term  myasthenia  gas- 
trica, because  atony  is  essentially  deficient  ac- 
tivity of  the  smooth  muscular  fibers  associated 
with  reduced  elasticity  of  the  gastric  wall,  and 
because  the  terms  atonia  and  mechanical  in- 
sufficiency signify  too  little.  We  see  that 
Ewald's  and  Boas's  definitions  of  motoric  insuf- 
ficiency differ.  Rosenbach  terms  as  gastric 
insufficiency  the  disproportion  between  the  ca- 
pacity of  the  muscular  forces  and  the  demand 
made  upon  them,  and  he  enumerates  three 
causes  which  bring  on  this  disproportion; 
among  others  he  mentions  nervous  weakness  of 

[10] 


SPLASHING   SOUND   OF   STOMACH 

the  muscles  of  the  stomach.  Buch  says  atonia 
and  myasthenia  can  not  be  identical  with  in- 
sufficiency; he  prefers  the  name  myasthenia. 
If  he  had  said  atonia  or  myasthenia  it  would 
have  been  more  correct,  as  we  shall  see.  The 
Greek  word  "  asthenia "  corresponds  with  the 
English  "  infirmity  "  ;  they  both  mean  sickness. 
However  we  may  translate,  there  is  some  indis- 
tinctness; the  only  word  to  the  point  which 
signifies  exactly  the  pathological  condition  is 
atonia  or  relaxation.  One  author  says  :  "  My- 
asthenia and  atonia  are  to  be  distinguished,  one 
from  the  other."  How  is  this  possible  ?  I  do 
not  know,  for  there  is  no  myasthenia  without 
atonia  and  no  atonia  without  myasthenia. 

Boas  is  of  the  opinion  that  myasthenia  isa 
primary  weakness  of  the  muscles  caused  by 
nervous  influences  and  has  to  be  considerd  sepa- 
rately, and  that  this  would  be  scientific  as  well 
as  practical.  He  further  says  the  weakness  of 
the  muscles  with  loss  of  elasticity,  which  occurs 
sooner  or  later  in  ectasis  caused  by  stenosis  of 
the  pylorus,  was  called  by  older  writers  atonia, 
and  he  concludes  that  myasthenia  is  the  cause 


ATONIA   GASTRICA 


of  insufficiency,  atonia  one  of  its  consequences. 
Summing  up  all  these  definitions,  we  have  a 
regular  gallimatias. 

In  order  to  show  how  necessary  it  is  to  clear 
up  the  existing  confusion  in  regard  to  these 
terms,  let  us  quote  at  hazard  from  a  paper  of  E. 
W.  Andrews  in  The  Journal  of  the  American 
Medical  Association  iQX  October  6,  1900,  enti- 
tled "  The  Reefing  Operation  for  Movable  Kid- 
ney "  :  "  Nephropexy  will  often  fail  in  wander- 
ing kidney  brought  about  by  gastroptosis  and 
enteroptosis."  It  is  difficult  to  see  how  this 
author  imagines  that  wandering  kidney  can  be 
brought  about  by  gastroptosia.  It  sounds  as 
tho  one  should  say  bellyache  brought  about  by 
the  belly ;  it  is  tohu  wabohu.  The  same  paper 
treats  of  a  case  in  which  the  right  kidney  de- 
scended so  far  as  to  touch  the  bladder,  and  was 
easily  palpated  in  any  position,  but,  as  the 
author  adds,  there  was  no  enteroptosis.  This 
is  a  regular  tohu  wabohu. 

In  simple  atony,  only  the  tonic  contraction  is 
weakened,  and  this  condition  may  exist  for 
years,  even  for  life,  without  developing  to  such 
[12] 


SPLASHING   SOUND   OF   STOMACH 

a  form  as  is  characterized  by  motor  insafficiency 
with  rete.fltion  and  in  higher  degrees  with  stag- 
nation of  ingesta. 

The  three  different  degrees  of  relaxation  can 
thus  be  diagnosticated  by  means  of  the  splash- 
ing sound :  Splashing  sound,  which  can  be  elic- 
ited only  during  the  normal  period  of  digestion, 
means  simple  atony;  splashing  sound  produced 
after  the  legitimate  time  of  digestion  has  ex- 
pired means  motor  insufficiency;  and  splashing 
sound  produced  in  the  morning,  after  the  night's 
fasting,  before  liquid  or  food  has  been  intro- 
duced, may  mean  stagnation,  dilatation  of  the 
stomach,  as  understood  by  most  writers,  or,  as 
it  is  also  called,  ectasis,  and  by  other  names. 
To  be  exact,  when  there  is  stagnation  of  food 
over-night,  we  find  splashing  sound  in  the 
morning  before  any  food  has  been  introduced 
on  that  morning. 

Since  splashing  sounds,  as  we  have  seen,  may 
be  a  proof  of  retarded  expulsion,  we  may  in 
many  instances  arrive  at  a  diagnosis  without 
inducing  the  sound,  so  much  dreaded  by 
most  patients;  our  diagnosis  can  be  made 
[13] 


ATONIA   GASTRICA 


by  means  of  a  few  slight  tappings  on  the 
abdomen. 

Altho  not  in  all,  but  in  most,  cases  gastrop- 
tosia  is  the  cause  of  dyspepsia,  in  extreme  cases 
we  find  reflex  vomiting  and  reflex  cough.  We 
can  obtain  conclusive  evidence  of  the  relation 
of  gastroptosia  to  dyspepsia,  and  the  reflex 
symptoms,  by  relieving  the  gastroptosia  by 
means  of  plaster  strapping,  as  I  have  described 
it.  With  the  relief  of  the  gastroptosia  by 
strapping  we  relieve,  as  a  rule,  dyspepsia  and 
reflex  symptoms. 

In  a  great  many  cases  in  which  the  splashing 
sound  can  be  produced  without  presenting  dys- 
peptic symptoms,  we  may  find  nervous  disor- 
ders, especially  so-called  neurasthenia.  It  is  a 
fact,  altho  not  yet  generally  known,  that  nerv- 
ous derangements,  caused  by  gastroptosia,  are 
as  frequent,  numerous,  and  manifold  as  nervous 
derangements  caused  by  uterine  displacements ; 
just  as  in  cases  of  what  we  might  call  ptoseo- 
dyspepsia  we  can  show  the  relation  to  gastrop- 
tosia, so  can  we  show  the  relation  of  gastrop- 
tosia by  relieving  the  ptosis  by  means  of  the 
[14] 


SPLASHING   SOUND   OF   STOMACH 

strapping  of  the  abdomen  with  adhesive  plaster. 
Ptoseo-dyspepsia  often  passes  under  the  name 
nervous  dyspepsia — a  thing  v^^hich,  I  believe, 
does  not  exist,  since  there  is  probably,  in  every 
case  of  so-called  nervous  dyspepsia,  an  anatomi- 
cal basis  to  be  found. 

Wherever  I  have  found  neurasthenia  in  a  pa- 
tient on  whom  I  could  produce  the  splashing 
sound,  I  applied  the  method  of  strapping  the 
abdomen,  and  numerous  are  the  cases  in  which 
this  simple  treatment  relieved  the  nervous 
symptoms. 

It  appears  that  some  writers  of  the  present 
time  make  it  a  special  point  to  speak  with  dis- 
dain of  the  significance  of  the  splashing  sound ; 
in  reality,  however,  there  exist  few  pathological 
symptoms  which  are  of  such  great  practical 
value  as  that  of  the  splashing  sound,  and  at  the 
same  time  require  so  little  skill  to  be  made  ser- 
viceable. 

The  chemical  examination  of  the  contents  of 

the  stomach  will  not  suffice  for  the  diagnosis ; 

the  presence  of  the  splashing  sound  is  of  value 

in  diagnosticating  the  abnormal    state  of  the 

[15] 


ATONIA  GASTRICA 


mechanical  functions  of  the  stomach.  We 
know  that  this  mechanical  part  has  paramount 
influence  on  the  further  process  of  digestion; 
if  only  this  part  is  normal,  other  conditions 
lacking,  digestion  may  go  on,  all  the  same, 
without  material  disadvantage.  Therefore  the 
examination  for  the  splashing  sound  will  be  in- 
dispensable ;  it  will  always  be  of  supreme  im- 
portance whenever  we  examine  a  patient  for 
gastric  disorder. 

Directly,  and  by  itself  alone,  the  splashing 
sound,  whenever  it  can  be  produced,  is,  as  stated 
before,  a  means  of  diagnosis  for  determining 
the  lower  border  and  the  dimensions  of  the 
stomach. 

Together  with  Dr.  Einhorn  I  have,  in  the  lat- 
ter's  clinic  in  the  German  Dispensary  (medi- 
cal department — men),  examined  a  hundred 
patients,  without  selection,  for  the  splash- 
ing sound,  in  accordance  with  the  following 
scheme :  I  wrote  down  how  long  a  time  it  was 
since  the  patient  had  partaken  of  food;  then  we 
examined  the  patient  for  the  splashing  sound — 
first,  without  giving  him  water  to  drink.  If  the 
[i6] 


SPLASHING   SOUND    OF   STOMACH 

symptom  could  not  be  elicited,  the  patient  was 
given  half  a  glass  of  water  and  then  examined 
again.  We  noted  whether  the  symptom  could 
be  produced  easily  or  with  difficulty.  After  I 
had  recorded  the  result  in  my  table,  I  wrote 
down  the  diagnosis  of  the  case  from  the  dispen- 
sary record. 

In  the  accompanying  table  (see  pages  19  to 
22)  are  given  the  results  of  a  hundred  cases 
examined  for  the  splashing  sound. 

In  thirty  cases  no  splashing  sound  could  be 
elicited.  In  six  of  these,  food  had  been  taken 
only  from  one-half  to  two  hours  before  exami- 
nation. In  two  cases  no  result  was  obtained,  on 
account  of  invincible  tension  of  abdominal  wall. 
In  one  case  the  symptom  was  found  six,  in  two 
seven,  in  one  eight,  and  in  one  twelve  hours 
after  eating.  In  sixteen  cases  the  splashing 
sound  could  be  elicited  as  far  down  as  or  below 
the  umbilicus.  Out  of  these  sixteen  cases  there 
were  only  nine  in  which  gastric  symptoms  had 
been  complained  of.  In  thirty-three  cases,  with 
splashing  sound,  there  were  no  gastric  com- 
plaints. In  three  cases  with  grave  gastric  af- 
2  [17] 


ATONIA  GASTRICA 


factions  (two,  carcinoma  ventriculi;  one,  gas- 
tritis chronica)  the  splashing  sound  could  not  be 
elicited.  In  those  two  of  carcinoma  the  exam- 
ination had  been  made  three  and  a  half  and  two 
hours  respectively  after  eating. 

Diseases  of  the  stomach  are  often  associated 
with  diseases  of  the  apparatus  of  circulation  and 
the  apparatus  of  respiration.  In  fact,  all  dis- 
eases of  long  duration  and  weakening  character 
go  together  with  affections  of  the  stomach. 
Thus,  for  instance,  in  nineteen  out  of  twenty- 
four  cases  of  heart  and  pulmonary  diseases  we 
find  the  existence  of  this  splashing  sound  re- 
corded in  our  table. 


[I8] 


SPLASHING   SOUND   OF   STOMACH 


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[19] 


ATONIA  GASTRICA 


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ATONIA   GASTRICA 


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[22] 


II 

METHODS    FOR    LOCATING   THE   PO- 
SITION   OF   THE    STOMACH 

By  ROBERT   C.   KEMP,  M.D.,  New  York. 

For  an  intelligent  understanding  of  this  sub- 
ject, it  will  be  necessary  to  define  those  condi- 
tions which  constitute  an  abnormality  in  the 
position  of  the  stomach  and  to  differentiate  be- 
tween them. 

Dilatation  of  the  stomach  may  be  due  to  gen- 
eral atonia  gastrica  or  exist  without  other  ab- 
dominal relaxation,  as  the  result  of  spasm,  or  of 
either  benign  or  malignant  stricture  of  the  py- 
lorus, and  there  are  varying  degrees  of  motor 
insufficiency,  even  in  marked  dilatation  of  the 
stomach. 

If  there  is  atony  of  the  stomach  with  motor 
insufficiency,  the  patient  having  gastric  symp- 
toms while  the  lower  border  of  the  stomach  is 
defined  at  a  level  of  the  umbilicus,  the  lesser 
[23] 


ATONIA   GASTRICA 


curvature  maintaining  its  relations  to  the  dia- 
phragm, we  may  then  consider  the  organ  to  be 
dilated.  The  muscular  fibers  first  elongate  in 
the  vertical  direction  and  the  distance  between 
the  lesser  and  the  greater  curvature  is  increased. 
Dilatation  may  also  ensue  in  the  transverse  and 
anteroposterior  dimensions,  and  the  pylorus  may 
be  a  little  farther  to  the  right  and  in  a  slightly 
lower  plane,  while  the  lesser  curvature  main- 
tains its  relation  to  the  diaphragm,  and  this  is 
the  differential  point  between  dilatation  and 
ptosis  of  the  stomach.  As  remarked  already, 
there  is  no  ptosis  without  dilatation;  but  we 
distinguish  dilatation  without  ptosis  by  consid- 
ering the  relation  of  the  lesser  curvature  to  the 
diaphragm. 

The  differential  diagnosis  can  be  arrived  at 
with  absolute  certainty  by  means  of  translumi- 
nation  of  the  stomach.  Some  also  claim  that, 
during  translumination,  the  light  follows  the 
respiratory  movements  with  dilatation,  but  does 
not  do  so  with  ptosis,  and  consider  this  a  sec- 
ond differential  point.  My  own  observations 
do  not  confirm  this  view. 
[24] 


THE  POSITION   OF  THE   STOMACH 

On  the  other  hand,  with  ptosis  the  suspen- 
sory ligaments  of  the  stomach  are  relaxed  and 
the  entire  organ  sinks,  the  lesser  curvature  as 
well  as  the  greater ;  and,  in  aggravated  cases,  the 
lesser  curvature  looks  inward  to  the  right,  the 
greater  curvature  outward  to  the  left,  and  the 
pylorus  may  often  lie  below  the  level  of  the 
umbilicus.  The  ptosis  of  the  intestine,  which 
is  attached  to  the  pylorus,  readily  explains  the 
semirotation  of  the  stomach  on  purely  mechan- 
ical grounds. 

As  we  see,  the  downward  displacement  of  the 
stomach  is  associated  with  change  of  its  form. 
It  assumes  in  the  higher  degrees  of  such  dis- 
placement either  the  shape  of  a  loop,  with  its 
convexity  down,  or  a  vertical  position,  similar 
to  that  of  the  fetal  period ;  or,  again,  a  vertical 
direction  has  developed,  by  the  sinking  down  of 
the  pylorus  to  such  an  extent  that  the  pylorus 
stands  nearly  vertically  below  the  cardiac  orifice. 

I  might  state  that,  tho  Dr.  Einhorn  employs 
the  term  ischochymia  (retention  of  chyme)  in 
place  of  dilatation  of  the  stomach,  I  prefer  the 
latter  name,  as  more  generally  accepted.     In 

[25] 


ATONIA   GASTRICA 


addition,  the  retention  of  chyme  is  the  result  of 
the  condition  of  atony. 

Having  described  the  chief  abnormalities  in 
the  position  of  the  stomach,  for  a  clear  under- 


*i'^ 


Fig.  I.  — Normal  Position. 


Fig.  2.— Ptosis. 


Standing  of  our  subject  it  would  seem  necessary 
to  map  out  the  normal  position  of  the  organ. 

The  cardiac  orifice  lies  a  little  to  the  left  of 
the  sternal  junction  of  the  seventh  left  cartilage 
(seventh  rib),  on  a  line  with  the  eleventh  dorsal 
vertebra.  It  lies  about  four  to  four  and  a  half 
inches  from  the  anterior  surface  of  the  abdo- 
men, 

[26] 


THE  POSITION   OF  THE   STOMACH 

The  pylorus  lies  between  the  right  sternal 
and  parasternal  lines,  slightly  below  the  tip  of 
the  ensiform  process,  and  corresponds  to  the 
body  of  the  first  lumbar  vertebra.  It  descends 
slightly  when  the  stomach  is  distended. 

The  greater  curvature,  when  the  stomach  is 
normally  distended,  lies  about  two  to  three  fin- 
gers' breadths  (one  and  one-half  to  two  and  one- 
quarter  inches)  above  the  umbilicus.  The 
fundus  rises  as  high  as  the  lower  border  of  the 
left  fifth  rib  in  the  mammillary  line,  slightly 
above  and  behind  the  apex  of  the  heart. 

The  anterior  surface  is  overlapped  above  by 
the  liver,  the  left  lung,  and  the  seventh,  eighth, 
and  ninth  ribs.  When  the  organ  is  distended 
with  food  the  lesser  curvature  is  directed 
obliquely  backward  toward  the  spine.  The 
colon  (transverse),  even  when  partially  distend- 
ed, may  overlap  the  greater  curvature,  and  the 
latter  itself  tends  to  fall  away  from  the  abdomi- 
nal wall  when  the  patient  is  in  the  dorsal  posi- 
tion. 

The  average  length  from  fundus  to  pylorus  is 
ten  to  twelve  inches ;  from  the  lesser  to  the 

[27] 


ATONIA  GASTRICA 


greater  curvature,  four  to  five  inches ;  from  the 
anterior  to  the  posterior  wall,  about  three  to 
three  and  a  half  inches.  The  lesser  curvature 
varies  in  length  from  three  to  six  inches,  and 
the  cardiac  orifice  and  the  pylorus  lie  much 
closer  together  than  is  often  supposed.  The 
cardiac  orifice  will  lie  in  a  slightly  higher  plane 
than  the  pylorus,  but  if  we  draw  a  plane 
through  the  latter,  the  lesser  curvature  will  be 
found  to  lie  in  a  plane  nearly  parallel  to  the 
plane  of  the  diaphragm. 

Methods  of  Examination. — On  the  day  or 
night  previous  to  examination  the  bowel  should 
be  thoroughly  emptied  by  a  cathartic.  If  there 
be  much  tympanitis  on  the  day  of  examination, 
this  should  be  relieved  by  a  hot  enema,  and,  if 
the  condition  be  very  marked,  then  rectal  irri- 
gation with  normal  saline  solution  at  i  io°- 
120°  F.  should  be  performed  with  the  Kemp 
tube. 

This  recurrent  irrigator  acts  like  a  Sprengel 
air-pump  and  carries  off  the  gas  in  a  most  sat- 
isfactory manner. 

The  first  method  that  we  employ  in  mapping 

[28] 


THE  POSITION   OF  THE   STOMACH 

out  the  position  of  the  stomach  is  by  inspec- 
tion. 

Inspection. — A  recognizable  bulging,  dis- 
tinct from  the  epigastrium,  especially  if  it  occur 
in  the  umbilical  or  hypogastric  region,  may  be 


Fig.  3.— The  Kemp  Tube. 

due  to  a  dilated  stomach;  the  epigastrium 
under  these  conditions  is  usually  hollow  and 
depressed.  This  method  may  prove  to  be  of 
assistance  in  thin  patients,  especially  if  the 
stomach  is  distended  with  gas. 

Peristaltic  motion  of  the  portion  of  the 
dilated  stomach  that  protrudes  is  at  times  ob- 
served. 

Kussmaul  has  noted  very  active  peristaltic 
motion  in  the  dilated  stomach  (peristaltic  un- 
rest), the  waves  passing  from  the  linea  alba 
below  the  umbilicus  in  an  upward  direction  and 
to  the  right  to  the  lower  margin  of  the  liver. 
[29] 


ATONIA   GASTRICA 


We  may  facilitate  inspection  by  placing  the 
patient  upon  a  raised  table,  the  head  toward  the 
window,  the  shades  being  arranged  so  that  the 
light  enters  on  a  plane  only  slightly  above  that 
of  the  patient,  and  the  rays  of  light  are  directed 
from  the  head  toward  the  feet.  The  examiner, 
standing  toward  the  foot  of  the  table  and  bend- 
ing from  side  to  side,  can  at  times  make  out 
shadows  cast  by  the  inequalities  of  the  abdomen. 
These  shadows  move  with  respiration.  By  this 
method  the  size,  shape,  and  position  of  the 
stomach  can  often  be  made  out. 

Knapp  places  the  patient  in  the  same  posi- 
tion, but  stands  at  the  side  or  at  the  shoulders, 
and  brings  his  eyes  down  to  the  level  of  the  ab- 
domen and  observes  the  respiratory  waves  pass- 
ing over  its  surface.  After  some  experience 
one  can  detect  delicate  transverse  lines,  or 
waves,  passing  upward  and  downward  with  res- 
piration. These  lines  correspond  with  the 
curvatures  of  the  stomach.  Tho  I  quote  these 
methods,  I  have  only  secured  occasional  suc- 
cess with  them  myself. 

The  following  signs,  however,  I  have  found 
[30] 


THE   POSITION   OF  THE   STOMACH 

quite  reliable.  With  the  patient  in  the  recum- 
bent position,  a  marked  concavity  between  the 
costal  arches — extending  from  the  ensiform 
process  to  or  below  the  umbilicus,  with  a  verti- 
cal median  sulcus,  wider  above  than  below,  the 
abdomen  being  flattened  in  the  central  part  and 
bulging  in  the  lateral  regions — is  significant  of 
stomachoptosia.  In  the  erect  position  the  epi- 
gastrium becomes  still  more  depressed,  while 
the  umbilical,  and  especially  the  pubic  regions, 
bulge  outward. 

Palpation  of  the  Stomach. — Inspection 
should  be  supplemented  by  palpation.  Palpa- 
tion should  be  performed  gently  and  the  hands 
of  the  operator  should  be  warm. 

The  patient  should  be  in  the  dorsal  position 
with  the  legs  drawn  up,  in  order  to  relax  the 
abdominal  muscles.  The  patient  should  also 
breathe  naturally,  and  keeping  the  mouth  open 
often  aids  relaxation.  The  physician  should 
preferably  be  seated  on  the  right  side  of  the 
bed  and  palpate  with  the  right  hand,  which 
should  be  flat  or  slightly  bent  upon  the  abdo- 
men, with  the  ulnar  side  downward.  One  can 
[31] 


ATONIA   GASTRICA 


stroke  from  above  downward,  and,  with  practise, 
it  is  possible  in  some  cases  to  feel  the  stomach- 
wall  and  appreciate  the  position  of  the  greater 
curvature,  as  the  stomach  gives  a  more  uni- 
formly elastic  sensation  than  do  the  intestinal 
walls.  On  the  other  hand,  some  commence 
palpation  from  below  and  work  upward,  dipping 
in  the  ulnar  edge  of  the  hand  rather  deeply. 
By  this  means  it  is  at  times  possible  to  deter- 
mine the  position  of  the  greater  curvature. 

By  means  of  palpation  we  can  readily  deter- 
mine whether  nephroptosia  be  present.  Under 
inspection,  we  have  already  noted  the  signs  that 
are  significant  of  gastroptosia.  If,  in  addition, 
we  find  a  "  fioating  kidney,"  this  renders  our 
diagnosis  quite  conclusive. 

One  of  our  valuable  methods  of  locating  the 
lower  border  of  the  stomach  and  as  an  adjunct 
in  mapping  out  its  boundaries  is  the  splashing 
sound,  treated  of  in  the  first  chapter. 

Percussion  of  the  Stomach. — The  accurate 
determination  of  the  position  and  size  of  the 
stomach  is  often  very  difficult  by  simple  percus- 
sion. The  sound  varies,  according  to  whether 
[32] 


THE  POSITION  OF  THE  STOMACH 

the  organ  is  empty  or  filled  with  air  or  food  and 
water.  The  position  of  the  patient,  whether 
lying  down,  semi-oblique,  or  standing,  modifies 
the  results.  In  order  to  obtain  any  results,  the 
stomach  should  contain  some  air.  Dehio,  for 
example,  has  demonstrated,  both  on  living  sub- 
jects and  on  the  cadaver,  that  if  the  stomach  is 
empty  the  tympanitic  sound  which  we  produce 
on  percussion  is  due  to  the  colon  and  not  to  the 
stomach;  since  the  latter  is  contracted  into  the 
left  concavity  of  the  diaphragm  and  is  not  in 
contact  with  the  anterior  thoracic  wall.  Hence 
the  time  at  which  the  examination  is  made  is 
important.  Moreover,  the  lower  ctirvaticre 
tends  to  fall  away  from  the  abdominal  wall. 

The  patient  should  first  be  examined  in  the 
dorsal  position  with  the  knees  flexed. 

This  method  determines  with  fair  accuracy 
the  upper  right  portion  and  upper  left  portion. 
The  use  of  the  plessimeter  is  sometimes  an  aid 
to  percussion.  The  absolute  determination  of 
the  lower  border  by  percussion  is  more  difficult. 
It  is  rendered  easier  if  the  bowels  have  been 
thoroughly  emptied,  since  the  colon  is  then  less 
3  [33] 


ATONIA   GASTRICA 


likely  to  ride  over  the  greater  curvature.  The 
percussion  sound  over  the  colon  is  lighter  and 
does  not  equal  that  over  the  stomach.  The 
stomach  sound  is  of  greater  intensity  and  clear- 
ness and  of  higher  pitch.  This,  of  course,  re- 
fers to  conditions  when  air  is  present  as  the 
factor.  Food  or  fecal  contents  alter  the  result, 
which  is  further  modified  by  percussion  in  the 
semi-oblique  and  standing  positions,  I  con- 
sider the  splashing  sound  the  more  accurate 
method  of  determining  the  lower  border  of  the 
stomach. 

Auscultatory  Percussion. — In  this  method 
we  employ  the  stethoscope.  The  chest-piece 
may  be  placed  above  the  seventh  rib  in  the  left 
mammillary  line,  or  between  the  tip  of  the 
ensiform  process  and  the  left  costal  margin,  or 
in  the  same  vertical  line,  but  slightly  below 
these  points.  One  should  first  percuss  near  the 
stethoscope,  to  fix  the  characteristic  sound. 
The  tympanitis  of  the  stomach  is  transmitted 
generally  through  the  liver  and  lung.  The  per- 
cussion should  be  begun  well  distant  from  the 
possible  location  of  the  stomach,  and  should  be 
[34] 


THE  POSITION   OF  THE   STOMACH 

performed  in  the  vertical  direction,  downward 
and  upward  and  also  laterally.  One  should  be- 
gin nearly  at  the  symphysis  and  percuss  in  ver- 
tical lines  upward.  The  patient  should  be  in 
tiie  usual  position,  as  heretofore  described,  and 
should  hold  the  stethoscope  for  the  operator 
against  the  abdomen.  A  sound  of  greater  in- 
tensity and  clearness  and  of  higher  pitch  de- 
notes the  border  of  the  stomach.  The  greater 
bulk  of  the  organ,  when  dilated  or  in  a  condi- 
tion of  ptosis,  lies  to  the  left  of  the  median 
line.  We  must  remember,  however,  that  some 
cases  of  marked  dilatation  extend  a  great  dis- 
tance to  the  right  of  the  abdomen. 

A  new  method,  recently  reported  as  being  of 
value  in  determining  the  position  of  the  stom- 
ach, is  by  the  use  of  Reichmann's  ascultatory 
percussion-rod.  This  consists  of  a  short  ivory 
rod,  with  circular  grooves  and  intervening  pro- 
jections, somewhat  like  the  handle  of  a  large 
ivory  knitting-needle.  The  rod  is  pushed 
firmly  down  over  the  stomach  at  a  right  angle 
to  its  surface  (in  a  vertical  line  to  the  abdo- 
men), and  is  gently  stroked  with  the  finger. 
[35] 


ATONIA  GASTRICA 


The  stethoscope  is  applied  over  the  organ  and 
the  "  pitch  "  carefully  observed.  When  the  rod 
passes  beyond  the  limits  of  the  stomach  a 
change  in  "  pitch  "  is  observed.  It  is  claimed 
that  the  boundaries  of  the  organ  can  thus  be 
mapped  out.  I  have  seen  this  employed  in  sev- 
eral cases,  but  examination  by  other  methods, 
notably  by  translumination,  demonstrated  the 
results  secured  by  the  rod  to  be  incorrect.  The 
originator  of  the  method  and  some  of  his  disci- 
ples, however,  claim  excellent  results. 

Flicking. — The  index  and  middle  fingers  of 
the  left  hand  are  pressed  down  on  the  abdomen. 
The  middle  finger  of  the  right  hand  is  pressed 
firmly  against  the  last  phalanx  of  the  thumb 
and  is  then  suddenly  released,  striking  a  sharp 
blow  against  the  fingers  exerting  pressure. 
This  acts,  as  it  were,  like  the  plessimeter. 
Good  results  are  claimed  from  this  method  of 
percussion. 

Inflation    of  the   Stomach  with  Carbonic 

Acid  Gas. — This  method  is  employed  in  order 

to  render  the  stomach  visible  to  inspection,  if 

possible;  also  to  aid  the  determination  of  the 

[36] 


THE  POSITION   OF   THE   STOMACH 

position  of  the  lesser  curvature,  as  well  as  the 
greater,  and  to  enable  a  differential  diagnosis 
between  dilatation  and  gastroptosia. 

The  simplest  method  is  to  administer,  first, 
a  half-glass  of  water  in  which  about  a  dram  of 
tartaric  acid  is  dissolved,  and,  after  this,  an- 
other half-glass  of  water  containing  a  dram  to  a 
dram  and  a  half  of  soda  bicarbonate.  If  small 
quantities  are  employed  the  stomach  will  not 
become  visible  and  palpable. 

There  are  certain  objections  to  this  method. 
At  times  there  is  considerable  escape  of  gas 
through  the  cardiac  orifice  or  pylorus,  and  the 
small  intestine  may  be  distended  in  some  cases. 
This  is  a  possible  source  of  error.  Also  on  some 
occasions,  especially  in  gastroptosia,  what  was 
apparently  stomach  becoming  protuberant  on 
the  abdominal  wall  was  demonstrated  by  trans- 
lumination  to  be  intestines  forced  out  forward 
and  laterally  by  the  stomach.  There  may  be 
sudden  hyperdistention  of  the  stomach,  with 
resulting  pressure  on  heart  and  lungs,  and  un- 
pleasant or  even  dangerous  symptoms  result, 
especially  in  a  patient  suffering  from  cardiac 
[37] 


ATONIA   GASTRICA 


disease.  When  there  has  been  a  hemorrhage, 
or  signs  of  ulcer  or  cancer,  or  signs  of  perito- 
nitic  trouble,  the  use  of  this  method  is  contra- 
indicated.  Several  fatal  accidents  have  oc- 
curred. It  also  sometimes  irritates  the  mucous 
membrane.  My  chief  objection  to  the  method 
is  that  the  quantity  of  gas  is  not  under  control. 
One  could  employ  a  stomach- tube  and  Dr. 
Rose's  small  carbonic-acid  gas  generating-bottle 
as  a  substitute.  Carbonic-acid  gas  inflation  is 
worthy  of  trial  in  those  who  are  in  fair  physical 
condition. 

Inflation  of  the  Stomach  with  Air. — The 
method  consists  in  introducing  a  soft  stomach- 
tube  and  slowly  pumping  air  into  the  stomach 
by  means  of  a  double  bulb  or  a  Davidson's  syr- 
inge. The  tube  should  be  introduced  with  the 
patient  sitting  up  in  bed,  and  he  should  then 
gently  recline  on  the  back,  and  inflation  should 
then  be  carried  out.  This  method  possesses  the 
advantage  that  the  amount  of  air  pumped  into 
the  stomach  can  definitely  be  regulated.  Thus 
one  can  fill  a  vessel  with  a  liter  of  water,  in- 
vert it  over  a  pail  of  water,  and  note  how  many 
[38] 


THE   POSITION   OF   THE   STOMACH 

compressions  of  the  bulb  displace  the  given 
quantity  of  fluid.  He  can  thus  measure  the 
quantity  of  air  pumped  in.  The  first  few 
squeezes  of  the  bulb  should  be  given  rapidly,  so 
as  to  cause  spasmodic  closure  of  the  pylorus. 
The  same  indications  and  contraindications  ex- 
ist for  this  method  as  for  the  use  of  carbonic 
acid  gas,  with  the  advantage  of  being  able  to 
regulate  more  definitely  the  degree  of  inflation. 
Some  patients  object  to  the  passage  of  the 
tube,  which  is  of  fair  size.  In  any  event,  if 
there  is  discomfort  from  either  method  of  infla- 
tion, the  condition  should  be  immediately  re- 
lieved by  the  passage  of  the  stomach-tube. 

One  author,  Fiirbringer,  suggests  that  when 
we  inflate  with  air  the  tube  should  be  intro- 
duced only  to  the  middle  of  the  esophagus,  and 
air  should  then  be  pumped  in.  He  claims  that 
this  method  prevents  retching. 

Inflation  of  the  Stomacli  with  Water. — To 
Dehio  we  must  give  the  credit  of  devising  the 
most  scientific  method  of  determining  the  posi- 
tion of  the  stomach  by  means  of  water  inflation. 
He  percusses  over  the  patient's  stomach,  the 
[39] 


ATONIA   GASTRICA 


organ  preferably  empty  and  in  the  erect  posi- 
tion. He  then  administers  a  glass  of  water, 
eight  ounces,  not  too  cold,  and  percusses  the 
area  of  dulness ;  he  then  administers  a  second, 
third,  and  fourth  glass  of  water,  percussing  in 
each  event  and  noting  carefully  the  position  and 
extent  of  the  dulness.  The  patient  is  then 
directed  to  lie  on  his  back,  and  tympanitis  will 
appear  where  dulness  was  before.  This  conclu- 
sively demonstrates  that  the  area  corresponded 
to  the  stomach.  If  there  is  pronounced  dilata- 
tion or  ptosis,  a  single  glass  of  water  will  often 
cause  dulness  to  appear  below  the  navel  or  in 
the  inguinal  region.  The  results  may  be  ob- 
scured in  patients  with  much  adipose  or  if  there 
is  fecal  accumulation  in  the  colon.  In  this 
event  it  should  be  cleared  out  by  injection,  I 
have  also  found  the  following  method  of  value, 
especially  if  there  be  some  gastric  contents : 
first  place  the  patient  in  the  semi-obliqite  posi- 
tion and  percuss  the  stomach ;  then  administer 
two  or  even  three  glasses  of  water.  We  then 
secure  stomach  tympanitis  above,  then  a  band 
of  stomach  dulness  and  intestinal  tympanitis 
[40] 


THE  POSITION   OF  THE   STOMACH 

below.  It  is  easier  to  differentiate  between 
dulness  and  tympanitis  than  between  two 
types  of  tympanitis.  There  are  numerous 
other  complicated  methods  by  means  of  inflata- 
ble bags,  manometers,  etc.,  for  determining  the 
position  of  the  stomach,  which  are  scarcely  of 
practical  value.  Leube  introduces  a  stiff  sound 
and  determines  the  position  of  its  lower  end 
through  the  abdominal  walls.  This  method 
would  not  seem  to  be  especially  safe.  Others 
differentiate  between  the  stomach  and  colon  by 
inflating  the  colon  with  air  or  carbonic  acid, 
employing  the  same  methods  as  in  the  stomach, 
only  using  twice  the  quantity  of  soda  bicarbo- 
nate and  tartaric  acid.  Rose's  apparatus  would 
prove  to  be  valuable  to  inflate  the  bowel.  To 
further  differentiate,  water  was  given  by  stom- 
ach. On  the  other  hand,  some  first  empty  the 
bowel  thoroughly  and  then  inflate  the  intestine 
with  water.  It  is  often  difficult  for  the  patient 
to  hold  the  enema.  There  are  also  two  other 
methods  which  are  of  value  in  determining  the 
lower  margin  of  the  stomach  :  First,  the  admin- 
istration of  small  quantities  of  soda  bicarbonate 
[41] 


ATONIA   GASTRICA 


and  tartaric  acid  with  the  patient  in  the  stand- 
ing position.  In  some  cases  one  can  approxi- 
mately map  out  the  lower 
border  of  the  stomach,  by  list- 
ening to  the  "  sizzling  sounds  " 
with  the  stethoscope.  This  may 
at  times  be  serviceable.  Sec- 
ond, the  use  of  the  stomach 
whistle  (Fig,  4).  This  con- 
sists of  a  rectal  tube  of  small 
caliber,  with  a  whistle  in  the 
end.  To  the  other  extremity  is 
attached  an  ordinary  stomach 
aspirating  bulb  without  valves. 
The  tube  is  inserted,  the  finger 
placed  over  the  open  end  of  the 
bulb,  and  a  single  bulb  full  of 
air  is  forced  into  and  aspirated 
out  of  the  stomach  by  rapid  and 
short  intermittent  contractions. 
This  entirely  eliminates  the  pos- 
sible chance  of  distending  the 
stomach  with  air  and  the  organ 

A 
[42] 


Fig.    4. — K  e  m  p  '  s  .  ^  •       1 1  t 

Stomach  Whistle,  remains  practically  empty 


THE   POSITION   OF  THE   STOMACH 

stethoscope  is  placed  over  the  abdomen  and  the 
point  of  greatest  intensity  of  sound  is  marked 
by  a  cross  with  a  colored  pencil.  The  tube  is 
pushed  in  and  out  and  the  various  points  of  sound 
are  marked ;  the  lowest  is  the  lower  border  of  the 
stomach.  The  ear,  of  course,  can  be  applied  in 
place  of  the  stethoscope.  Translumination  of 
the  organ  was  then  performed  and  the  lower 
margins  absolutely  corresponded.  I  am  per- 
fectly cognizant  of  the  method  of  administering 
water  and  then  blowing  air  into  the  stomach 
through  a  tube,  but  the  "  bubbling  sounds  "  only 
give  the  level  of  the  fluid  and  not  accurately  the 
lower  margin  of  the  stomach.  The  whistle  is 
therefore  of  value  in  this  regard,  tho  it  will  not 
necessarily  differentiate  between  dilatation  and 
gastroptosia.  This  experiment  with  the  stom- 
ach whistle  further  demonstrated  that  in  the 
standing  position  the  stomach,  even  when  emp- 
ty, descends  to  the  full  length  of  its  suspensory 
ligaments  at  once,  and  its  lower  border  is  prac- 
tically at  a  constant  level  or  within  about  an 
inch  of  the  same,  whether  the  organ  be  full  or 
empty ;  for  it  was  at  the  same  level  when  a  pint 
[43] 


ATONIA   GASTRICA 


or  more  of  fluorescent  fluid  had  been  ingested 
as  when  then  demonstrated  by  translumination. 

One  of  our  most  scientific  methods  of  loca- 
ting the  position  of  the  stomach  and  differen- 
tiating between  dilatation  and  gastroptosia  is 
by  gastrodiaphany,  or  translumination  of  the 
stomach.  It  also  enables  us  accurately  to  de- 
termine the  degree  to  which  these  conditions 
have  attained,  and  may  modify  our  prognosis 
and  treatment. 

Translumination  of  the  Stomach. — In  1845 
Casenave  first  applied  the  method  of  trans- 
lumination to  living  tissues.  In  1867  Milliot 
succeeded  in  transluminating  the  stomachs 
of  animals  and  experimented  with  the  stom- 
achs of  cadavers,  but  to  Dr.  Max  Einhorn, 
of  New  York,  the  credit  is  due  of  being  the 
first  to  demonstrate  translumination  of  the 
stomach  on  the  living  subject  and  the  practical 
value  of  gastrodiaphany.  His  instrument, 
which  he  denominates  a  gastrodiaphane,  con- 
sists in  effect  of  a  soft-rubber  stomach-tube,  at 
one  end  of  which  is  fastened  an  Edison  lamp. 
Conducting  wires  run  through  the  tube  to  the 
[44] 


THE   POSITION   OF  THE   STOMACH 


battery,  and  there  is  a  current-interrupter  at 
some  distance  from  the  tube.  The  lamp  is  en- 
closed in  a  glass  bulb, 
to  act  as  a  reflector 
and  prevent  the  action 
of  heat  on  the  stomach 
(Fig.  5).  He  has  the 
patient  drink  one  or 
two  glasses  of  water, 
so  as  not  to  distend  the 
stomach,  inserts  the 
light,  and  examines  the 
patient  in  a  dark  room, 
either  in  the  sitting  or 
in  the  recumbent  posi- 
tion. 

Heryng  and  Reich- 
man  employ  a  modified 
tube,  with  a  water- 
cooler  about  the  lamp. 
They  first  pass  a  stom- 
ach-tube and  pour  in 
from  a  pint  to  two  quarts  of  water,  examining  in 
the  erect  position.  Kutner  and  Jacobson,  under 
[45] 


-Einhorn's  Gastrodia- 
phane. 


ATONIA   GASTRICA 


Ewald's  direction,  performed  a  great  number  of 
experiments.  They  first  used  a  gastrodiaphane 
with  an  inflow  and  outflow  tube,  and  later  a 
single  tube  with  an  inflow  above  the  lamp,  in- 
troducing the  water  through  this  after  the  light 
has  entered  the  stomach.  These  experiment- 
ers, together  with  Meltzing,  are  the  chief  for- 
eign investigators  with  gastrodiaphany.  M. 
Manges,  Stockton,  and  many  others  have  em- 
ployed the  method.  Among  various  gastrodia- 
phanes  are  those  of  Hemmeter,  Lincoln,  Solis- 
Cohen,  Koplik,  and  Lockwood.  To  Lockwood 
we  must  credit  a  decided  advance  in  the  type  of 
instrument — a  fine,  wire- wound  cable  (rubber 
insulated)  and  a  small  light,  no  larger  than  a 
five-grain  capsule.  The  cut  of  my  own  instru- 
ment, the  "circumscribing  gastrodiaphane," 
will  sufficiently  explain  the  Lockwood  instru- 
ment, after  which  it  is  modeled,  with  certain 
modifying  additions. 

The  Circumscribing  Gastrodiaphane. — Dur- 
ing the  past  two  years  a  careful  series  of  obser- 
vations with    translumination   of  the  stomach 
suggested  to  me  an  improvement  on  the  gastro- 
[46] 


THE  POSITION   OF  THE   STOMACH 

diaphanes  now  in  use.  Manipulation  of  the 
tube  after  the  electric  ball  has  entered  the 
stomach  frequently  causes  gagging  and  at  times 
vomiting,  interfering  thus  with  the  accuracy  of 
the  method.  The  cables  of  all  the  instruments 
were  found  unsatisfactory  in  case  of  gastrop- 
tosia  of  great  degree  when  we  endeavored  to 
explore  carefully  the  pyloric  end  of  the  greatly 
dilated  stomach.  In  addition,  it  was  impossible 
to  guide  the  light  in  a  definite  direction ;  it 
would  sometimes  pass  to  the  right,  sometimes 
to  the  left,  and  often  it  was  necessary  to  draw 
it  in  and  out  a  number  of  times  a  distance  of 
several  inches. 

The  instrument  which  I  devised  to  overcome 
these  drawbacks  has  a  cable  about  six  inches 
longer  than  the  Lockwood  gastrodiaphane,  and 
is  of  about  the  same  caliber.  The  cable  is 
somewhat  more  flexible  for  the  space  of  a  quar- 
ter of  an  inch — about  the  same  distance  from 
the  light — in  effect  a  joint  at  this  point.  At 
the  base  of  the  light  is  attached  an  extremely 
thin  accessory  cable,  covered  with  rubber. 
This  runs  parallel  with  the  main  cable  and  prac- 
[47] 


ATONIA  GASTRICA 


tically  increases  the  diameter  to  only  a   very 
slight  degree.     After  introduction   of  the  in- 


FlG.  6. — Circumscribing'  Gastrodiaphane. 


[48] 


THE  POSITION   OF   THE   STOMACH 

strument  the  main  cable  is  held  firmly  and  the 
accessory  cable  drawn  upon  by  turning  the  cable 
at  the  same  time;  the  instrument  can  be  di- 
rected in  any  desired  direction.  In  addition  to 
this,  by  manipulation  of  the  accessory  cable,  the 
main  cable  can  be  so  bent  that  the  light  will 
explore  the  entire  wall  of  the  stomach  ante- 
riorly and  can  be  made  to  pass  up  to  the  pylo- 
rus and  along  the  borders  of  the  ribs.  It  is 
thus  kept  under  definite  control.  Care  should 
be  taken  that  the  cables  are  parallel  when 
passed  into  the  stomach,  and  the  accessory  ca- 
ble should  be  relaxed  before  withdrawal.  The 
main  cable,  except  at  the  joint  near  the  light, 
is  somewhat  stiffer  than  the  Lockwood  light. 
Eight  dry-cells  are  employed  with  a  rheostat. 
The  cover  of  the  battery  case  has  a  clip  and 
supports  for  carrying  the  gastrodiaphane,  so 
that  an  extra  box  is  unnecessary.  There  is  also 
an  arrangement  for  an  extra  lamp  in  case  of  ac- 
cident. Water  was  the  medium  formerly  em- 
ployed, several  glasses  of  it  being  administered 
before  the  light  was  passed. 

One  of  the  greatest  advances  in  the  technic 
4  [49] 


ATONIA  GASTRICA 


of  translumination  of  the  stomach  is  the 
employment  of  fluorescent  media.  There  are 
three  fluorescent  media  so  far  found  to  be  of 
value:  (i)  Bisulfate  of  quinin,  gr.  x.  in  a 
pint  of  water.  The  addition  of  TTl  v.  of  dilute 
phosphoric  acid  intensifies  its  action.  The 
same  amount  of  dilute  sulfuric  acid  may  be 
substituted.  The  reaction  of  the  quinin  solu- 
tion is  in  itself  acid  and  the  fluorescence  a 
very  pale  violet.  Increased  acidity  intensifies 
its  action  and  fluorescence  disappears  if  the 
solution  is  rendered  alkaline.  (2)  Esculin;  this 
is  derived  from  the  ^sadas  hippocastanum 
(horse-chestnut),  indigenous  to  Europe.  Fif- 
teen-grain doses  have  been  used  in  malaria. 
One  can  employ  small  doses,  gr.  yi  to  gr.  ^  in 
a  pint  of  alkaline  solution,  which  gives  a  blue 
fluorescence.  This  preparation  is  diflicult  to 
secure.  (3)  Fluorescein  phthalic  anhydrid  (5 
parts),  a  naphthalin  product,  and  resorcin  (7 
parts)  heated  to  200°  C.  (392°  F.).  It  is  a  red- 
dish powder,  faintly  soluble  in  water  with  a  neu- 
tral reaction  and  practically  gives  thus  no  fluor- 
escence ;  soluble  in  alcohol  and  in  alkaline  media, 
[50] 


THE  POSITION   OF   THE   STOMACH 

giving  a  green  fluorescence  like  liquid  opal.  It 
has  been  employed  to  detect  ulcers  of  the  cornea. 
It  can  be  secured  from  Merck  &  Co.,  and  is  ex- 
tremely cheap.  No  further  literature  was  ob- 
tainable. I  therefore  injected  one  to  two  grains 
of  fluorescein  into  dogs  and  rabbits  in  alkaline 
and  alcoholic  solutions,  with  no  resulting  effects 
either  physiological  or  local.  Later,  assisted 
by  Mr.  Ferry,  the  chemist  of  St.  Bartholomew's 
Clinic,  we  further  investigated  its  properties- 
He  suggested  to  me  the  addition  of  glycerin  to 
intensify  the  fluorescence,  and  we  found  that 
the  hydrochloric  acid  of  the  stomach  must  first 
be  neutralized.  The  patient  should  first  be 
given  a  glass  of  water  (8  oz.),  in  which  gr.  xv. 
of  bicarbonate  of  soda  have  been  dissolved.  A 
second  glass  of  water  (8  oz.)  is  then  adminis- 
tered, in  which  are  dissolved  the  same  amount 
of  sodium  bicarbonate,  3  i.  of  glycerin,  and  gr. 
}i  to  gr.  }(  of  fluorescein.  One  to  two  ounces 
of  lime  water  may  be  substituted  for  the  sodium 
bicarbonate.  Curiously  enough,  as  we  increase 
the  fluorescein  in  strength,  fluorescence  dimin- 
ishes and  colorization  begins.  By  means  of 
[51] 


ATONIA  GASTRICA 


fluorescent  media,  I  have  found  it  possible  to 
illuminate  the  stomachs  of  fat  or  muscular 
subjects,  that  were  formerly  unsatisfactory,  to 
examine  for  tumors  and  the  location  of  the 
stomach  with  greater  accuracy,  and  I  believe 
that  I  can  fairly  state  that  the  brilliancy  of  the 
illumination  is  increased  many  times. 

Examination  of  the  urine  of  patients  who  had 
taken  fluorescein  shows  no  deleterious  effects — 
no  albumin,  no  sugar,  no  casts.  Tho  fluores- 
cein acts  in  an  alkaline  medium  and  free  acid 
destroys  fluorescence,  yet  on  catheterization  of 
these  patients  greenish  fluorescent  urine  is  ob- 
tained one  hour  after  the  administration  of  flu- 
orescein solution,  and  this  condition  persists  for 
about  four  hours.  The  acidit}^  of  the  urine  is 
not  due,  however,  to  the  presence  of  free  acid. 
Dr.  Ferd.  Valentine  has  thus  demonstrated  that 
fluorescein  solution  added  to  acid  urine  causes 
it  to  fluoresce.  In  fluorescein  solution  we  have 
an  additional  means  of  testing  the  permeability 
of  the  kidneys. 

The  technic  of  gastrodiaphany  is  as  follows  : 
The  patient's  stomach  should  be  empty.     He 
[52] 


THE   POSITION   OF  THE   STOMACH 

is  given  a  glass  (8  oz.)  of  the  alkaline  solution, 
and  then  a  second  glass  of  fluorescein  solution 
(8  oz.).  I  frequently  give  an  extra  half  or  full 
glass  of  water.  A  dark  room  gives  the  only 
satisfactory  results.  It  can  readily  be  impro- 
vised, by  pinning  blankets  across  the  windows. 
The  gastrodiaphane  is  introduced  by  gaslight  or 
candle  light,  the  patient  sitting  opposite  you  in 
a  chair,  with  the  abdomen  exposed.  The  elec- 
tric current  is  turned  on  and  the  room  darkened. 
The  patient  should  then  stand  up,  as  this  posi- 
tion is  preferable.  It  is  my  custom  to  mark 
out  the  anatomical  regions  on  the  abdomen  of 
each  case  with  blue  pencil,  and  then  draw  the 
outlines  of  the  stomach  during  translumina- 
tion.  I  have  already  carefully  defined  the 
differential  diagnosis  between  dilatation  and 
gastroptosia.  With  gastroptosia  the  lesser  cur- 
vature can  be  determined.  In  some  cases  the 
stomach  will  be  bottle-neck  above,  with  the  base 
below,  or  somewhat  pear-shaped,  the  narrow 
part  above,  as  the  light  disappears  beneath  the 
ribs.  In  a  dilated  stomach  the  transverse  di- 
ameter of  translumination  is  nearly  the  same ; 
[S3] 


ATONIA   GASTRICA 


as  we  withdraw  the  light  it  only  begins  to  nar- 
row just  below  the  tip  of  the  ensiform.  If  we 
illuminate  in  the  dorsal  position,  the  light 
hardly  shows  at  all ;  it  becomes  clearer  as  the 
patient  gradually  sits  erect,  and,  finally,  is  most 
marked  in  the  standing  position.  This  substan- 
tiates the  view  of  Meltzing,  who  states  that  in 
the  dorsal  position  only  a  portion  of  the  stom- 
ach is  in  contact  with  the  abdominal  wall,  and 
it  further  demonstrates  the  necessity  of  the 
standing  position  for  accurate  illumination. 

In  the  following  illustrations  (Fig.  7,  A-H) 
are  shown  a  normal  stomach,  the  dilated  organ, 
and  several  degrees  of  gastroptosia.  There  is 
no  question  but  that  ptosis  of  the  stomach  exists 
from  a  very  slight  to  an  extreme  degree,  and  in 
some  of  the  patients  iiephroptosia  is  not  present, 
especially  in  the  mild  types. 

The  next  method  of  locating  the  position  of 
the  stomach  to  which  I  shall  refer  is  by  means 
of  the  ;r-ray.  I  shall  speak  of  it  only  briefly, 
and  my  readers  must  consult  some  standard 
work  on  skiagraphy  for  the  subject. 

X-ray. — One  can  administer  subnitrate  of 
[54] 


THE   POSITION   OF   THE   STOMACH 


[55] 


ATONIA   GASTRICA 


bismuth  in  capsules,  and,  by  means  of  the  x- 
ray  and  the  fluoroscope,  define  the  position  of 
these  capsules  in  the  lower  part  of  the  stomach, 
and  hence  the  lower  border  (greater  curvature) 
can  be  mapped  out.  On  the  other  hand,  a  bis- 
muth emulsion  can  be  administered  and  the 
position  of  the  organ  observed  by  the  same 
method.  The  stomach  can  also  thus  be  photo- 
graphed by  the  ;r-ray. 

In  addition,  Dr.  Sinclair  Tousey,  of  New 
York,  has  experimented  with  defining  and  pho- 
tographing the  stomach,  by  employing  fluores- 
cent media  combined  with  radioactive  solutions. 
The  fluorescent  media  were  after  the  formulae 
described  by  the  author  under  translumination. 
For  a  description  of  these  experiments,  we 
would  refer  to  the  article  by  Dr.  Tousey,  en- 
titled "  The  Relation  of  the  ;tr-Ray  and  Ra- 
dioactive Solutions  to  Examination  of  the 
Stomach "  {New  York  Medical  Journal  and 
Philadelphia  Medical  Journal,  May  21,  1 904). 
These  methods  just  described  necessitate  an 
expensive  apparatus  and  are  only  suitable  for 
office  work.  For  accuracy  and  brilliancy  of  re- 
[56] 


THE  POSITION   OF  THE   STOMACH 


suits  in  clearly  locating 
the  position  of  the  stom- 
ach, they  do  not  compare 
with  translumination. 
In  an  article  entitled 
"  Observations  on  Radi- 
um "  (The  Medical  Rec- 
ord, July  30,  1904),  Dr. 
Max  Einhorn,  of  New 
York,  describes  a  method 
of  translumination  of  the 
stomach  with  radium,  by 
means  of  a  device  which 
he  calls  the  radiodia- 
phane  (Fig.  8).  This 
consists  of  a  hard-rubber 
capsule,  containing  0.05 
gm.  of  pure  bromide  of 
radium  (1,000,000 
strength).  This  lies  at 
the  end  of  a  soft-rubber 
tube,  connected  with  an 
inflating  bulb.  There  are 
small  openings  near  the 
[57] 


■  —  „.^ 


Fig.  8.— The  Radiodiaphane. 
(Einhorn.) 


ATONIA  GASTRICA 


capsule,  on  the  end  of  the  tube  or  connecting 
joint,  so  that  air  can  be  pumped  into  the  stom- 
ach, the  inventor  having  demonstrated  that  bet- 
ter results  are  obtainable  in  an  air  medium  than 
with  fluid.  The  patient  should  preferably  be 
examined  on  an  empty  stomach.  The  radiodi- 
aphane  is  moistened  with  water  and  introduced 
into  the  stomach.  Kahlbaum'  s  fluoroscope  is 
applied  to  the  upper  left  abdominal  wall.  The 
examination  must  be  made  in  an  absolutely 
dark  room,  and  it  usually  takes  two  or  three 
minutes  to  accustom  the  eyes  to  the  darkness. 
A  figure  is  then  observed  resembling  the  stom- 
ach and  of  the  color  of  the  moon.  Around  this 
a  faint  halo  may  be  seen  to  the  left  above  the 
stomach,  up  to  the  ensiform  process,  to  the  left 
axillary  line,  and  even  to  the  left  side  of  the 
back,  where  it  is  much  fainter.  The  lungs 
above  the  stomach  and  diaphragm  are  illu- 
minated. To  the  right  the  liver  does  not  trans- 
mit the  rays  and  the  screen  remains  dark.  If 
the  screen  is  moved  farther  down  over  the  ab- 
domen the  illumination  usually  ceases  below 
the  large  curvature.  Besides  we  observe  a  very 
[58] 


THE   POSITION   OF  THE   STOMACH 

intense  spot  of  illumination  (about  the  size  of 
a  big  walnut),  which  corresponds  to  the  position 
of  the  radium  capsule.  If  air  is  insufflated  into 
the  stomach  the  illumination  is  more  marked. 
On  deep  inspiration  the  illumination  becomes 
weaker  (probably  on  account  of  the  greater  dis- 
tance of  the  abdominal  wall  from  the  radium 
capsule) ;  on  deep  expiration,  however,  the  illu- 
mination becomes  much  brighter.  When  the 
radiodiaphane  is  withdrawn,  one  observes  how 
the  intensely  illuminated  area  (of  the  size  of  a 
walnut)  travels  upward,  to  disappear  in  the  re- 
gion of  the  ensiform  process.  When  the  in- 
strument again  descends  into  the  stomach,  the 
light  at  once  reappears. 

The  originator  of  the  method  states  that  the 
stomach  can  be  examined  laterally  and  to  the 
left  of  the  back,  regions  that  are  inaccessible  to 
the  gastrodiaphane.  The  position  of  the  greater 
curvature  can  also  be  readily  determined  by  this 
method.  The  author  has  no  personal  experi- 
ence as  to  this  method.  Radium  we  know  to 
be  extremely  costly  and  the  radiodiaphane  is 
an  expensive  instrument,  and  the  proper  trans- 
[59] 


ATONIA   GASTRICA 


lation  of  the  results  secured  requires  special 
technical  skill.  For  the  mere  determination  of 
the  position  of  the  stomach,  the  simpler  meth- 
ods should  be  advocated  for  the  general  profes- 
sion. I  note  with  interest,  however,  that  Dr. 
Einhorn  has  determined  an  intrathoracic  tumor 
by  radiodiaphany,  and  further  experimentation 
in  this  field  is  well  worthy  of  trial. 

I  have  described,  therefore,  at  considerable 
length  the  various  methods  for  locating  the 
position  of  the  stomach,  and,  for  the  benefit  of 
the  general  practitioner,  I  shall  briefly,  in  clos- 
ing, refer  to  the  most  suitable  methods.  On 
inspection,  the  anatomical  conformation  pecul- 
iar to  gastroptosia  is  readily  appreciated,  and 
palpation  will  at  least  define  a  floating  kidney, 
if  such  be  present.  Securing  these  data,  we  are 
quite  certain  of  gastroptosia.  Some  cases  of 
ptosis,  however,  do  not  present  the  typical  ap- 
pearance on  inspection,  and  some  mild  cases 
exist  without  appreciable  nephroptosia.  The 
splashing  sound  is  of  great  value.  Percussion 
and  auscultatory  percussion  are  of  value,  espe- 
cially the  latter  in  some  cases,  and  we  should 
[60] 


THE  POSITION   OF  THE  STOMACH 

examine  in  the  dorsal  position  with  the  knees 
flexed,  and  also  in  the  semi-oblique  and  stand- 
ing positions.  The  bowels  in  all  cases  should 
be  emptied  before  examination.  Inflation  of 
the  stomach  with  carbonic  acid,  or  with  air,  or, 
finally,  with  water,  is  a  valuable  adjunct.  The 
employment  of  water,  such  as  Dehio's  method, 
is  of  service.  The  production  of  sizzling 
sounds  in  the  standing  position,  by  administer- 
ing small  quantities  of  tartaric  acid  and  sodium 
bicarbonate  or  by  the  use  of  the  stomach  whis- 
tle, will  accurately  determine  the  position  of 
the  lower  border  of  the  stomach.  Finally,  in 
gastrodiaphany,  translumination  of  the  stom- 
ach, we  have  an  ideal  method  for  differential 
diagnosis  between  dilatation  of  the  stomach  and 
gastroptosia.  It  also  determines  accurately  the 
degree  of  dilatation  or  ptosis,  and  gives  one 
a  basis  on  which  to  decide  the  question  of 
operative  procedure.  The  new  gastrodiaphane, 
which  Dr.  Rose  has  denominated  "  circumscri- 
bing," is  certainly  an  advance  in  technic.  Re- 
cently,   for  example,    I  was  enabled  to  direct 

the  light  into  the  fundus  of  the  stomach  to  the 
[6i] 


ATONIA  GASTRICA 


left  border,  so  that  I  could  see  by  lateral  trans- 
hmiination  that  the  stomach  lay  behind  the 
enlarged  left  lobe  of  the  liver,  cirrhotic  in  ori- 
gin. The  peculiarity  of  the  case  was  that  the 
enlargement  was  confined  to  the  left  lobe, 
and  illumination  was  absolutely  shut  off  in 
front.  This  is  certainly  of  value.  Further- 
more, the  use  of  fluorescent  media,  especially 
of  fluorescein,  has  increased  to  a  manifold  de- 
gree the  efficiency  of  gastrodiaphany.  The 
method  is  simple,  the  light  easy  to  pass  without 
discomfort  to  the  patient,  and  a  single  demon- 
stration is  sufficient  to  instruct  a  man  of  aver- 
age intelligence.  As  a  matter  of  interest  I  ap- 
pend references  to  the  latest  literature  on  the 
subject:  Post- Graduate,  February,  1904;  New 
York  Medical  Journal  and  Philadelphia  Med- 
ical Journal,  February  13,  1904,  "Fluorescein 
in  Translumination  of  the  Stomach " ;  Med- 
ical News,  April  30,  1904,  "A  New  Meth- 
od for  Translumination  of  the  Stomach  by 
Means  of  Fluorescent  Media,  etc." ;  Medical 
News,  August  6,  1904,  "Observations  on  Dila- 
tation of  the  Stomach  and  on  Gastroptosis " ; 
[62] 


THE  POSITION   OF  THE  STOMACH 

American  Medicine ^  Dr.  Solis- Cohen,  of  Phila- 
delphia, 1904;  Medical  Record,  Dr.  H,  Lin- 
coln, of  Brooklyn,  1904 ;  Post-Graduate,  Novem- 
ber, 1904,  "Circumscribing  Gastrodiaphane "  ; 
The  New  York  State  Joimial  of  Medicine,  Feb- 
ruary, 1905,  "The  Value  of  Translumination 
of  the  Stomach  as  an  Aid  to  Diagnosis " ; 
American  Medicine,  March  4,  1905,  "Mucou* 
Colic." 


[63] 


Ill 

ATONIA   GASTRICA   AND   A   NEW 
METHOD   OF   TREATMENT 

A  NUMBER  of  pathological  conditions  of  the 
stomach  are  caused  by  insufficient  activity  of 
its  muscular  fibers,  diminished  activity  of  its 
walls,  elongation  of  the  suspending  ligament  of 
the  lesser  curvature,  the  lesser  omentum,  and 
gastroptosia.  * 

These  disorders  may  be  associated  with  in- 
sufficiency of  motor  functions  and  retention  of 
the  contents  of  the  stomach  beyond  the  legiti- 
mate time;  and  all  these  conditions  have  one 

*  I  write  gastroptosia  instead  of,  as  I  formerly  did, 
gastroptosis,  because  a  Greek  feminine  noun  which  ends 
in  sis,  xis,  and  psis  as  the  second  component  remains  un- 
changed when  the  first  component  is  a  preposition,  as, 
for  instance,  proptosis,  periptosis,  diagnosis ;  but  if  the 
first  component  is  not  a  preposition,  then  in  composition 
the  ending  is  changed  into  sia,  as  eupraxia,  apraxia,  pal- 
ingenesia,  hierognosia,  and  also  gastroptosia. 
[64] 


A   NEW   METHOD   OF  TREATMENT 

thing  in  common,  the)'^  are  manifestations  of 
relaxation — relaxation  of  muscular  fibers,  of  the 
ligament,  of  the  walls,  of  the  stomach. 

The  word  gastroptosia,  correctly  translated, 
means  abdominal  ptosis  (falling),  not  necessa- 
rily ptosis  (falling)  of  the  stomach  alone.  This 
latter  would  be  stomachoptosia. 

The  word  gastroptosia,  or,  what  means  the 
same  thing,  atonia  gastrica,  is  a  good  term,  for 
there  is  as  a  rule  not  one  abdominal  organ  only 
descended,  altho  one  may  be  more  displaced 
than  the  other.  The  words  gastroptosia  and 
atonia  gastrica  are  good  terms  for  another  rea- 
son, namely,  because  they  include  the  relaxa- 
tion of  the  abdominal  walls.  For  reasons 
which  will  appear  presently  I  prefer,  as  the 
heading  of  this  chapter,  the  phrase  atonia  gas- 
trica. 

The  tone,  the  activity  of  the  abdominal  mus- 
cles, aids  in  fixing  the  abdominal  organs  in 
their  proper  physiological  position.  Relaxa- 
tion of  this  apparatus  is  the  essential  factor  in 
atonia  gastrica,  and  in  therapy  it  is  the  first 
factor  we  have  to  consider. 
5  [65] 


ATONIA   GASTRICA 


Enteroptosia  is  ptosis  of  the  abdominal  vis- 
cera in  general,  or,  so  far  as  literary  translation 
is  concerned,  it  may  mean  ptosis  of  viscera,  not 
necessarily  of  the  abdomen  alone.  Certainly 
we  may  understand  by  this  term  ptosis  of  the 
bowels,  but  this  is  arbitrary.  Splanchnoptosia 
means  also  ptosis  of  viscera,  not  abdominal  vis- 
cera exclusively.  Splanchnon  can,  for  instance, 
mean  the  heart.  I  simply  give  facts  which  are 
worth  knowing  when  we  have  science  at  heart. 

Those  who  have  given  the  word  atonia  gas- 
trica  the  meaning  of  motor  insufficiency  of  the 
stomach  have  caused  much  confusion. 

Atonia  gastrica  may  exist  without  motor  in- 
sufficiency. 

Myasthenia  gastrica  is  a  word  without  any 
definite  meaning. 

Motor  insufficiency  of  the  stomach  implies  a 
disproportion  between  the  capacity  of  the  mus- 
cular forces  of  the  stomach  and  the  demand 
made  upon  these  forces.  Such  insufficiency 
may  occur  under  certain  circumstances  in  a 
healthy  stomach,  when  the  mass  of  the  ingested 
food  is  too  large  or  the  nature  or  condition  of 
[66] 


A   NEW  METHOD   OF  TREATMENT 

the  ingesta  unsuitable.  Atony  may  cause  in- 
sufficiency, but  atony  is  not  itself  insufficiency. 
Atony  may  exist  without  insufficiency  when  the 
resistance  at  the  pylorus  is  subnormal.  Atony 
may  be  caused  by  insufficiency. 

There  exists  ectasis  or  dilatation  of  the  stom- 
ach, which  we  have  to  distinguish  from  gastrop- 
tosia,  but  there  is  no  gastroptosia  without  dil- 
atation. Gastroptosia  depends  on  relaxation, 
and  relaxation  of  the  fibers  of  muscles  means 
elongation  of  the  fibers;  therefore  relaxation  is, 
eo  ipso,  dilatation. 

For  practical  purposes  let  us  retain  the  word 
gastroptosia,  as  meaning  ptosis  of  the  stomach, 
as  part  of  abdominal  ptosis, 'dxi'di  in  contradistinc- 
tion to  ectasis  of  the  stomach  without  ptosis. 

In  abdominal  ptosis,  or  atonia  gastrica,  a  se- 
ries of  contributory  factors  comes  into  play, 
and  in  each  individual  case  there  are,  as  a  rule, 
a  number  of  such  factors  cooperating. 

Altho  in  most  cases  ptosis  of  several  viscera 
appears  simultaneously,  it  may  also  happen  that 
one  part  alone  is  sunk  down,  but  it  is  not  there- 
fore justifiable  to  attribute  symptoms  of  abdom- 
[67] 


ATONIA   GASTRICA 


inal  atony  or  ptosis  to  the  displacement  of  one 
organ  in  particular,  as  G16nard  has  done  in  se- 
lecting the  intestine,  and  as  a  great  many  phy- 
sicians were  wont  to  do  when  they  imagined 
that  the  floating  kidney  alone  was  the  guilty 
part. 

A  healthy  stomach  maintains  the  position  of 
its  lower  border  constant  in  all  positions  of  the 
body;  not  so  the  atonic  stomach.  The  latter 
changes  its  position  according  to  the  different 
positions  of  the  body.  While  the  patient  is  in 
the  upright  position,  the  lower  border — that  is, 
the  larger  curvature  as  well  as  the  pylorus — 
sinks  down.  In  the  recumbent  position  both 
will  rise,  and  changes  from  right  to  left  take 
place  according  as  the  body  assumes  a  different 
position.  Buch  explains  this  change  of  posi- 
tion as  being  due  to  elongation — that  is,  relax- 
ation of  the  suspending  ligament  of  the  lesser 
curvature — and  he  thinks  that  while  there  is  no 
atonia  gastrica  without  relaxation  of  this  liga- 
ment, neither  is  there  any  atonia  gastrica  with- 
out gastroptosia. 

Discussions  on  gastroptosia  have  been  very 
[68] 


A   NEW  METHOD   OF   TREATMENT 

lively  during  recent  years,  and  the  opinions  of 
the  different  authors  in  regard  to  its  etiology 
differ,  as  we  shall  see  in  the  chapter  on  history 
and  literature.  They  also  differ  with  regard  to 
a  number  of  morbid  conditions  which  have  been 
connected,  correctly  or  incorrectly,  with  gas- 
troptosia.  This  lively  controversy  has  been  the 
means  of  enlarging  our  knowledge  in  this  field 
of  investigation. 

There  can  be  no  doubt  that  it  is  of  para- 
mount importance  to  speak  first  of  the  etiology 
of  atonia  gastrica,  for  the  knowledge  of  the  eti- 
ology in  any  given  case  is  the  best  guide  for 
therapeutical  action.  Cases  of  atonia  gastrica 
are  of  importance  in  every-day  practise.  The 
pathological  changes  in  these  cases  are  subject 
to  special  therapy,  which  is  as  rational  as  it  is 
in  most  instances  successful. 

The  displacement  of  the  stomach  and  other 
abdominal  organs  is  often  an  acquired  condi- 
tion, but  recent  investigations  have  furnished 
evidence  that  a  congenital  predisposition  to  it 
generally  plays  a  most  essential  part  in  its 
causation. 

[69] 


ATONIA   GASTRICA 


In  accordance  with  different  etiological  con- 
ditions, we  have  to  distinguish  different  forms 
of  atonia  gastrica.  The  overlooking  of  this 
distinction  between  various  kinds  of  gastrop- 
tosia  of  diverse  origin  has  given  rise  to  many 
different  explanations.  The  different  forms  of 
gastroptosia  have,  according  to  their  etiology, 
distinct  significance. 

Gastroptosia  in  adults  of  both  sexes  may  be 
the  concomitant  of  constitutional  defects  and 
anomalies,  and,  first  of  all,  of  paralytic  thorax, 
chicken- breast,  or  funnel-shaped  breast.  We 
find  displacement  of  the  stomach  in  men  or 
nulliparae  of  tender  and  lean  habit,  with  narrow, 
long,  precociously  ossified  thorax,  wide  inter- 
costal spaces,  and  frequently  Stiller' s  stigma  of 
fluctuating  tenth  rib;  in  short,  it  is  found  in 
persons  with  typical  phthisical  habit.  Gas- 
troptosia is  indeed  very  frequently  met  with 
in  phthisical  patients,  but  rarely  in  strong  and 
robust  people  except  when  caused  by  trauma  or 
peritonitic  adhesions.  There  are  exceptional 
cases  of  movable  spleen  and  kidney,  even  stom- 
achoptosia  of  purely  local  nature,  happening  in 
1:70] 


A   NEW  METHOD    OF   TREATMENT 

robust  subjects;  in  such  cases  the  subjective 
painful  symptoms  may  be  missing.  On  the 
other  hand,  gastroptosia  is  frequent  in  poorly 
nourished  individuals  and  among  feeble  sales- 
women who  are  forced  to  be  standing  for  eight 
hours  or  more  during  the  day. 

The  reason  why  patients  with  long,  narrow 
thorax  are  specially  subject  to  gastroptosia  is 
this :  In  such  patients  the  diaphragm  occupies 
a  position  lower  down  than  normally,  on  ac- 
count of  the  increased  vertical  diameter  of  the 
lungs.  In  cases  of  emphysema  of  the  lungs 
and  exudation  in  the  pleural  cavity  there  is  still 
a  lower  level  of  the  diaphragm.  In  these  con- 
ditions the  organs  situated  below  the  dia- 
phragm can  not  find  sufficient  space  in  the  hy- 
pochondrium  and  are  obliged  to  descend.  In 
the  constitutional  form  it  is  not  often  that  the 
spleen  and  liver  are  sunk  down.  The  kidney, 
in  men  with  gastroptosia  of  the  constitutional 
form,  is  less  often  felt  than  in  cases  of  the  con- 
stitutional form  in  women. 

Among  my  cases  there  were  three  in  which 
the  symptoms  of  gastroptosia  had  been  relieved 
[71] 


ATONIA   GASTRICA 


completely;  there  was  no  more  abnormal 
splashing  sound  until  the  patients  had  intercur- 
rent diseases.  One  of  them  suffered  from  se- 
vere attacks  of  malaria,  and  the  two  others  had 
influenza.  When  I  saw  them  again  after  these 
affections,  gastroptosia  had  developed  anew  and 
the  splashing  could  be  easily  elicited  over  a 
large  area,  exactly  as  was  the  case  before  their 
first  treatment.  In  all  diseases  which,  like  ty- 
phoid fever,  cause  muscular  weakness  in  gen- 
eral, atonia  gastrica  will  develop  itself. 

Acquired,  especially  rachitic,  changes  of  the 
skeleton  may  cause  relaxation  of  the  abdominal 
viscera.  Stratz  has  thus  described  such  condi- 
tions :  When  the  sacrum  is  not  sufficiently 
broad,  the  spinae  ilii  anteriores  superiores  stand 
too  wide  apart  and  the  vaults  of  the  ilium  are 
flattened;  in  some  cases  the  width  of  the  spinse 
may  be  larger  than  the  width  of  the  cristae,  and 
all  this  causes  the  distance  between  the  points 
of  insertion  of  the  abdominal  muscles  to  be 
greater,  and  thus  their  support  to  be  weakened. 

The  downward  displacement  of  the  stomach 
is  associated  with  change  of  its  form.     It  as- 
[72] 


A   NEW  METHOD   OF  TREATMENT 

sumes  in  the  higher  degrees  of  such  displace- 
ment either  the  shape  of  a  loop  with  its  convex- 
ity down,  or  a  vertical  position  similar  to  that 
of  the  fetal  period ;  or,  again,  a  vertical  direc- 
tion has  developed  by  the  sinking  down  of  the 
pylorus  to  such  an  extent  that  the  pylorus 
stands  nearly  vertically  below  the  cardiac  ori- 
fice. 

Far-down  displacement,  marked  changes  of 
form,  and  real  disfigurements  of  the  stomach 
are  found  in  some  cases  of  kyphosis  and  scolio- 
kyphosis. Fleiner  describes  a  case  in  which 
the  splashing  sound  could  be  produced  immedi- 
ately over  the  symphysis,  while  the  apex  beat 
of  the  heart  was  felt  in  the  axilla.  In  this 
case,  however,  notwithstanding  these  anomalies 
in  the  situation  of  the  viscera,  there  existed  no 
marked  disturbance  of  the  gastric  functions. 

Next  to  the  constitutional,  there  are  other 
causes  due  to  local  and,  as  a  rule,  mechanical 
disorders,  and  these  disorders  may  exist  in  the 
stomach  itself  or  outside  of  it. 

Permanent  motor  insufficiency  produces 
stomachoptosia  (which  may,  however,  form  a 
[73] 


ATONIA   GASTRICA 


part  of  general  atonia  gastrica),  as  also  do  tu- 
mors of  the  pylorus  or  of  the  lesser  curvature 
which  are  weighing  on  the  stomach.  In  the 
latter  instances  the  expelling  power  of  the  or- 
gan may  remain  intact. 

Gastroptosia  may  be  caused  by  hernia — her- 
nia of  the  mesentery,  for  instance;  above  all, 
hernia  in  the  linea  alba  may  give  rise  to  gas- 
troptosia. In  these  casss  also  the  expelling 
power  of  the  stomach  may  remain  intact. 

Tumors  of  the  spleen  and  liver  may  also 
cause  gastroptosia.  Another  group  of  cases 
owes  its  existence  to  enlargement  of  the  ab- 
dominal space.  The  largest  contingent  of 
these  is  furnished  by  the  postpuerperal  types 
of  gastroptosia,  and  these  have  been  called 
Landau  cases,  because  Landau  first  described 
them  thoroughly.  This  form  of  gastroptosia 
may  exist  without  giving  rise  to  symptoms.  If 
a  woman  has  given  birth  to  many  children, 
there  occurs  a  physiological  relaxation  of  the 
abdominal  walls,  which  leads  to  a  physiological 
descent  of  the  viscera  of  moderate  degree  with- 
out symptoms.  The  Landau  form  will  be  well 
[74] 


A   NEW  METHOD   OF   TREATMENT 

pronounced  in  cases  of  women  in  whom  the 
spine,  in  its  lumbar  region,  is  abnormally 
curved  forward  (rachitic  affection),  and  who 
during  pregnancy  are  obliged — in  order  to  keep 
the  balance — to  bend  backward  while  the 
uterus  is  forced  forward  to  an  abnormal  de- 
gree. 

Men,  after  having  been  released  from  obesity 
by  heroic  diet  or  treatment,  may  acquire  gas- 
troptosia.  Gastroptosia  in  these  instances,  puer- 
peral as  well  as  after  obesity  cure,  is  the  result 
of  adaptation  to  space. 

As  mentioned  already,  the  activity  of  the 
abdominal  muscles  aids  in  a  manner  not  suffi- 
ciently explained  in  fixing  the  abdominal 
organs  in  their  physiological  position. 

Relaxation  of  this  apparatus  forms,  therefore, 
the  first  etiological  momentum  in  puerperal  and 
vci  post-obesitatem  enteroptosia.  It  is  true  that 
relaxation  of  the  abdominal  muscles  is  to  a  cer- 
tain degree  compensated  by  increased  expan- 
sion of  the  intestine,  but  a  complete  compen- 
sation is  hardly  ever  established.  Women  who 
do  not  receive  proper  attention  immediately 
[75] 


ATONIA   GASTRICA 


after  confinement  may  acquire  or  suffer  increase 
of  preexisting  gastroptosia. 

Glenard's  whole  theory  of  splanchnoptosia  is 
based  on  the  relaxation  of  the  suspensory  liga- 
ments of  the  intestines,  especially  that  of  the 
transverse  colon ;  and  Stiller,  the  discoverer  of 
the  floating  tenth  rib,  says  that  splanchnoptosia 
is  a  descent  of  the  atonic  stomach,  of  the  colon 
(especially  the  transverse  portion),  of  the  kid- 
ney (the  right  or  both  kidneys),  exceptionally 
of  the  liver  or  the  spleen;  a  descent  which  has 
been  developed  mostly  in  tender  age,  in  conse- 
quence of  general  relaxation,  especially  of  the 
peritoneal  suspensory  ligaments  in  individuals 
with  congenital  general  dyspeptic  neurasthenia, 
tender  muscles,  lean  habit,  and  slender  bone 
structure,  manifested  in  a  higher  degree  by  a 
floating  tenth  rib. 

The  same  author  remarks  :  "  Boas  takes  pains 
to  formulate  the  diagnostic  difference  between 
splanchnoptosia  and  nervous  dyspepsia,  but 
one  can  plainly  see  that  he  is  not  successful ; 
the  same  is  the  case  with  his  attempt  to  distin- 
guish gastric  motor  insufficiency  from  nervous 
[76] 


A   NEW  METHOD   OF   TREATMENT 

dyspepsia."  Splanchnoptosia  and  nervous  dys- 
pepsia are,  according  to  Stiller,  identical,  and 
gastric  motor  insufficiency  is  its  constant  and 
often  only  symptom.  As  we  have  seen,  there 
are  cases  of  gastroptosia  or  splanchnoptosia,  as 
it  is  called  by  Stiller,  without  dyspeptic  symp- 
toms, and  these  are  not  so  very  rare,  and  thus 
Stiller's  view  is  applicable  only  to  the  great 
majority  of  cases,  or  rather  it  applies  only  to 
cases  which  have  been  described  as  nervous 
dyspepsia. 

The  question  about  the  relation  of  typical 
gastroptosia  or  enteroptosia  or  splanchnoptosia 
or  atonia  gastrica,  whichever  term  we  may  se- 
lect, to  all  its  nervous  and  dyspeptic  concomi- 
tants and  to  the  well-known  picture  of  nervous 
dyspepsia,  has  been  answered  by  G16nard,  to 
the  effect  that  in  reality  there  is  no  nervous 
dyspepsia,  since  the  symptoms  are  produced  by 
changes  in  the  anatomical  position  of  abdominal 
organs. 

For  a  long  time  the  corset  and  the  strings 
with  which  the  skirts  are  fastened  around  the 
waist  were  said  to  play  an  important  role  in  the 


ATONIA   GASTRICA 


genesis  of  the  affection,  but  now  their  part  in 
causing  the  evil  has  been  decided  to  be  of  only 
moderate  measure.  In  those  cases  which 
would  be  of  most  importance  in  deciding  the 
question  as  to  what  part  the  corset  and  the 
skirt-strings  are  playing,  i.e.,  in  young  girls  and 
nulliparae,  it  appears  that  frequently  a  tight- 
fitting  corset  has  never  been  worn,  because  it 
could  not  be  tolerated.  It  is  undeniable  that 
tight-lacing,  tight  attachment  of  skirt-strings, 
will  aggravate  an  existing  gastroptosia,  because 
the  compression  of  the  abdomen  from  the  sides 
is  apt  to  cause  displacement  of  the  right  lobe 
of  the  liver  toward  the  middle,  and  thereby  to 
cause  pressure  on  the  pyloric  portion  of  the 
stomach,  thus  favoring  development  of  gastrop- 
tosia. 

Our  text-books  tell  us  that  stasis  in  the  ve- 
nous circulation  of  the  abdominal  cavity,  stasis 
caused  by  heart  disease,  and  stasis  in  the  sys- 
tem of  the  portal  circulation  give  rise  to  gastric 
atony. 

As  remarked  already,  it  is  a  well-established 
fact  that  there  exist  cases  of  gastric  atony 
[78] 


A   NEW  METHOD   OF  TREATMENT 

which  for  a  long  time  give  rise  to  no  symptoms. 
Boas  reports  the  case  of  a  seamstress  in  whom 
the  clinical  symptoms  of  such  atony,  associated 
with  retention  of  the  contents  of  the  stomach, 
was  accidentally  established,  altho  this  woman 
did  not  complain  of  any  suffering.  According 
to  Buch,  it  is  not  a  rare  occurrence  to  find,  on 
necropsy,  dilatation  of  the  stomach,  the  exist- 
ence of  which  during  lifetime  had  not  been 
suspected;  and  Pentzoldt  has  described  and  de- 
picted the  case  of  a  man  who  had  died  from 
diabetes  and  pulmonary  tuberculosis,  but  had 
never  complained  of  gastric  disorder.  On  au- 
topsy, considerable  ectasis  and  ptosis  of  the 
stomach  were  found,  and  the  walls  of  the  stom- 
ach were  remarkably  thin.  In  these  cases 
there  was  a  compensatory  activity,  thanks  to 
which  the  contents  of  the  stomach — notwith- 
standing the  high  degree  of  atony — entered  the 
intestine  in  proper  time.  The  compensation 
consisted  in  relaxation  of  the  ring  of  the  pylo- 
rus— that  is,  of  its  circular  muscular  fibers. 
This  compensation  presents  an  analogy  of  the 
compensation  in  valvular  diseases  of  the  heart. 
[79] 


ATONIA   GASTRICA 


Some  individuals  may  live  for  years  with  an 
abnormally  dilated  and  displaced  stomach,  com- 
plaining of  slight  if  any  symptoms,  as  do  indi- 
viduals vi^ith  serious  valvular  affections  of  the 
heart,  who  are  often  unaware  of  their  disease, 
so  long  as  the  compensatory  hypertrophy  of  the 
ventricle  is  adequate  to  counteract  the  defect 
in  the  valve. 

But  some  day  the  compensation  fails,  and 
then  appear  suddenly  or  in  surprisingly  short 
time  all  the  symptoms  of  stomach  dilatation.  It 
is  possible  that  some  of  the  instances  described 
as  acute  dilatation  of  the  stomach  may  belong 
to  this  category  of  cases  of  failing  compensa- 
tion. 

Relaxation  of  the  stomach  may  be  caused 
by  disease  confined  to  muscular  fibers,  through 
affection  of  their  innervation.  B.  Stiller  found, 
in  a  large  number  of  nervous  dyspeptics  with 
floating  kidney  and  splashing  stomach,  that 
the  tenth  rib  was  movable;  that  is,  movable 
to  such  a  degree  as  normally  the  eleventh 
and  twelfth  ribs  are  movable,  not  being  fast- 
ened by  cartilaginous,  but  only  by  ligamen- 
[80] 


A   NEW   METHOD    OF   TREATMENT 

tous,  structure  to  the  costal  arch.  He  observed 
that  when  there  is  such  a  floating  tenth  rib, 
there  are  likewise  a  floating  kidney  and  a  dis- 
placed stomach,  Altho  this  floating  rib  is  not 
found  in  every  case  of  gastroptosia,  it  was 
never  missing  in  well-pronounced  cases.  He 
thinks  that  the  degree  of  mobility  of  this  rib 
corresponds  with  the  degree  of  gastroptosia  and 
the  degree  of  neurasthenia,  while  the  degree  of 
mobility  of  the  kidney  does  not  allow  such  a 
deduction. 

He  found  children  who  had  floating  kidney 
with  and  without  a  floating  tenth  rib,  and  also 
children  with  it  but  without  floating  kidney  and 
witiiout  gastroptosia.  He  believes,  however, 
that  such  children  will  later  on  become  neu- 
rasthenics and  gastroptotics.  | 

He  further  observed  that  floating  rib,  ne- 
phroptosia,  and  gastroptosia  were  seldom  looked 
for  in  patients  of  advanced  years.  This  fact  is 
explained  by  the  circumstance  that  the  subjec- 
tive enteroptotic  symptoms  improve  with  ad- 
vancing years,  and  that  people  who  formerly 
had  consulted  the  physician  on  account  of  neu- 
6  [8i] 


ATONIA   GASTRICA 


rasthenia  would  not  visit  him  any  more  with 
complaints  inviting  examination  for  enterop- 
tosia. 

■  A  great  deal  has  been  written  on  the  relation 
between  anemia  and  chloriasis  in  young  girls 
and  displacement  of  the  stomach.  It  is  cer- 
tainly rational  to  assume  that  chloriasis  is  not 
the  result  of  gastroptosia,  but  the  manifesta- 
tion of  a  constitutional  anomaly  which  simulta- 
neously favors  the  disease  of  the  blood  and  the 
development  of  the  displacement.  There  exists 
chloriasis  without  gastroptosia,  and  there  is  a 
probability  that  chloriasis  may  have  been  the 
primary  evil,  causing  reduction  of  tone  of  the 
abdominal  muscles,  and  thereby  inducing  gas- 
troptosia. 

Men  afflicted  with  gastroptosia  present 
symptoms  of  general  nervous  irritability  less 
often  than  women. 

The  important  question  of  the  relation  of 
gastroptosia  to  nervous  symptoms,  which  latter 
are  of  frequent  occurrence  and  ^f  manifold 
kind,  has  been  touched  upon  already,  when  G16- 
nard's  and  Stiller's  views  were  given, 
[82] 


A   NEW  METHOD    OF   TREATMENT 

Some  authors  have  spoken  of  a  relation  be- 
tween hyperacidity  and  gastroptosia,  but,  ac- 
cording to  my  own  observation,  there  exists  no 
rule;  ptoseodyspepsia,  if  I  may  use  the  name 
which  I  have  suggested,  manifests  itself  simi- 
larly to  hysteria ;  the  symptoms  are  inconstant 
and  changeable,  some  cases  present  even 
achylia,  but  the  probability  is  that  hyperacidity 
is  more  frequently  found  in  gastroptosia, 

Atonia  gastrica  is  caused,  as  the  foregoing 
remarks  demonstrate,  mostly  by  constitutional 
weakness,  and  requires  tonics  in  general.  We 
have,  however,  to  deal  directly  with  the  me- 
chanical derangement,  and  it  is  rational  to  ap- 
ply mechanical  treatment  as  the  first  and  direct 
means  of  relief. 

As  stated  already,  the  activity  of  the  abdom- 
inal muscles  aids  in  fixing  the  abdominal 
organs  in  their  physiological  position.  Relax- 
ation of  this  apparatus  forms,  therefore,  a  factor 
in  gastroptosia,  and  it  is  the  first  factor  we 
have  to  consider  in  therapy. 

To  strengthen  the  abdominal  muscles,  differ- 
ent measures  have  been  suggested.  They  are, 
[83] 


ATONIA   GASTRICA 


in  the  first  place,  a  substitute  for  the  loss 
of  tone  by  means  of  a  bandage;  next,  hydro- 
therapy, massage,  electricity,  and  gymnastics. 
Cold  douches  to  the  abdomen  and  sitz- baths  of 
short  duration  have  been  tried.  Massage  exe- 
cuted secundum  artem  in  the  form  of  effleurage, 
petrissage,  and  tapotement,  in  connection  with 
Thure  Brandt's  Unternierettzitterwirkimg  and 
faradization  of  the  abdominal  walls,  intragastric 
faradization  and  galvanization,  have  also  had 
systematic  trial ;  but  the  results,  at  least  in  far- 
developed  cases,  were  unsatisfactory.  In  some 
instances  some  of  these  procedures  are  not 
harmless,  for  what  we  gain  on  the  one  hand  by 
invigorating  the  muscles,  we  may  lose  on  the 
other  by  irritating  the  psyche  of  a  hysterical 
person.  We  have  to  take  into  consideration 
that  we  are  dealing  with  the  nervous  condition 
of  a  patient.  But,  moreover,  all  these  remedies 
are  illusory  in  the  case  of  patients  of  the  work- 
ing class.  I  might,  however,  speak  favorably 
in  such  cases  of  massage  with  a  cannon-ball  of 
five  or  six  pounds'  weight,  which  is  cheap,  con- 
venient, and  perhaps  more  effective  than  mas- 
[84] 


A   NEW   METHOD   OF  TREATMENT 

sage  with  the  hands.  I  might  also  recommend 
swimming  for  such  cases,  when  in  season  and 
opportunity  is  offered ;  and  also,  as  productive 
of  some  good,  I  might  think  of  the  podylaton, 
commonly  but  horridly  or  barbarously  called 
bicycle. 

None  of  all  these  remedies  just  mentioned 
will  I  criticize  or  discard.  They  may  all  in 
their  turn  serve  as  accessaries  to  the  remedy 
which  has  given  me  more  satisfaction  in  grave 
cases  than  all  the  others  put  together. 

The  therapy  of  gastroptosia  consists  in  the  at- 
tempt to  give  tone  to  the  abdominal  walls,  and, 
if  this  can  not  be  attained,  to  find  a  substitute 
for  the  loss  of  tone  by  means  of  a  bandage. 
My  experience  has  been  scarcely  satisfactory 
with  bandages  as  they  are  made  by  the  patients 
or  the  bandager.  Except  in  Landau  and  cases 
of  obesity,  it  seems  difficult  to  have  a  well- 
fitting  bandage  made,  impossible  in  cases  of 
patients  of  lean  habit.  Recollecting  how  well  a 
broad  rubber  plaster  has  served  me  in  cases  of 
umbilical  hernia  when  cut  in  the  shape  of  the 
abdominal  wall,  tapering  off  behind,  and  secur- 
[85] 


ATONIA  GASTRICA 


ing  to  perfection  the  whole  abdomen;  recol- 
lecting, moreover,  how  well  such  strapping  has 
been  borne,  and  knowing  of  what  great  service 
it  proves  in  case  of  fractured  rib  and  in  some 
cases  of  pleurisy,  I  have  used  a  plaster  of  the 


form  and  in  the  manner  to  be  described  in  cases 

of  gastroptosia. 

At  first  I  applied  the  ordinary  rubber  plaster 

only.     A  piece  of   the  size   of   twenty-six   to 

thirty-six  or  more  inches,  as  the  case  may  be, 

by  seven  inches,  is  cut  as  shown  in  Fig.  9.  * 

*  The  sections  indicated  by  the  dotted  lines,  and  marked 
B  (see  Fig.  9)  are  separated  from  the  bandage  A,  and  laid 
upon  it  in  reversed  position  so  as  to  overlap  (see  Fig.  10). 
[86] 


A   NEW   METHOD   OF  TREATMENT 

The  large  piece  is  applied  as  tightly  as  pos- 
sible around  the  abdomen,  the  point  in  the 
middle  over  the  symphysis,  drawing  it  well  up- 
ward, while  the  narrow  ends  meet  and  overlap  at 
the  spine  (see  plates  I.  and  II.). 

The  plaster  should  not  include  the  crest  of 
the  ilium,  but  should  run  closely  along  and 
above  it.  The  support  of  the  abdominal  walls 
is  made  perfect  by  the  additional  application  of 
the  two  side  pieces  of  the  plaster,  extending 
from  the  hypogastrium  over  the  inguinal  and 
iliac  regions,  reaching  also  to  the  spine,  and 
overlapping  (see  plates  III.  and  IV.). 

In  applying  the  side  pieces  we  may  use  con- 
siderable force. 

In  many  instances,  especially  in  cases  of  full 
habit,  it  is  much  preferable  to  apply  the  two 
side  pieces  first  and  the  large  piece  last  (see 
plates  V.  and  VI.). 

The  plaster  has  been  applied  by  several  col- 
leagues, who  have  tried  the  method  in  different 
positions  of  the  patient — the  dorsal,  the  semi- 
oblique,  or  even  the  Trendelenburg  in  cases  of 
extreme  ptosis.  In  fact,  this  last  position  was 
[87] 


ATONIA   GASTRICA 


at  once  suggested  when  1  first  spoke  of  abdomi- 
nal strapping  for  gastroptosia  before  a  medical 
society. 

In  many  cases  it  happens,  sometimes  after  a 
few  days,  sometimes  after  one  or  two  weeks, 
that  the  plaster  becomes  loose  at  the  lower  mar- 
gin, from  the  symphysis  to  the  groin,  while  it 
remains  well  adherent  otherwise.  In  order  to 
guard  against  this  accident,  I  find  it  practical 
to  strengthen  this  border  by  applying  an  extra 
small  strip  of  plaster  all  along  the  lower  border, 
as  shown  in  plate  VII. 

Most  marked  and  prompt  relief  has  been 
afforded  in  such  cases  of  extreme  severity  in 
which  reflex  cough  and  reflex  vomiting  were 
among  the  symptoms.  Patients  whose  night's 
rest  had  been  interrupted  by  almost  constant 
coughing,  and  whose  nutrition  had  been  im- 
paired by  frequent  vomiting,  have  at  once  en- 
joyed comfort,  after  months  of  distress,  the  first 
night  after  strapping,  and  have  been  able  to  re- 
tain at  least  properly  selected  food,  which  they 
had  not  been  able  to  do  before  such  strapping. 
One  of  the  first  cases  of  this  kind  was  that  of  a 
[88] 


ATONIA  GASTRICA. 


PLATE  I. 


Pag-e  87. 

Application  of  Main  Piece  of  Plaster.     Front  view. 


ATONIA  GASTRICA. 


PLATE  II. 


Page  87. 
Main  Plaster  Applied,  Ends  Overlapping  at  the  Spine. 


ATONIA  GASTRICA. 


PLATE  III. 


Page  £, . 


Side  Pieces  of  Plaster  Applied.     Front  view. 


ATONIA  GASTRICA. 


PLATE  IV. 


Page  87. 


Plaster  Dressing  Complete.     Dorsal  view. 


ATONIA  GASTRICA. 


PLATE  V. 


Page  87. 


Side  Pieces  of  Plaster  Applied  First. 


ATONIA  GASTRICA. 


PLATE  VI. 


I-  ^'*;; 

it 

^m^  P 

^H« 

m 

\ 

^/m       -'^ 

^^^^1 

im 

L 

^^H 

^^K    :-^^ ' 

/mm 

'fW 

n 

bi 

^ 

n 

f 

.^  .,„^^^H 

1 

Page  87. 

Plaster  Dressing  Complete.     Side  pieces  applied  first, 
main  piece  last. 


ATONIA  GASTRICA. 


PLATE  VII. 


^ 


.^1 


Page  88. 

Plaster  Dressing  Completed  by  Additional  Strips  Ap- 
plied Over  the  Lower  Border. 


ATONIA  GASTRICA. 


PLATE  VIII. 


Fig.  I. 


Fig.  II. 


Fig.  III. 


Fig.  IV. 


Page  ic 


Rosewater's  Abdominal  Plaster  Strapping. 


A   NEW   METHOD    OF   TREATMENT 

woman  suffering  from  pulmonary  phthisis  asso- 
ciated with  gastroptosia.  Another  case  was 
that  of  a  hard-working  woman  with  gastropto- 
sia, who,  notwithstanding  her  reflex  coughing 
and  vomiting  during  an  enforced  application  to 
housework,  was  promptly  relieved.  It  is  pos- 
sible that  in  this  second  case  some  other  treat- 
ment in  the  end  might  have  been  successful ; 
but  to  subject  her  to  massage,  electricity,  or 
hydrotherapy  was,  on  account  of  her  circum- 
stances, out  of  the  question. 

At  the  time  when  I  first  presented  my  obser- 
vations before  the  New  York  Post-Graduate 
Clinical  Society,  on  December  22,  1899,  and 
again  before  the  American  Gastro-Enterological 
Association,  at  a  meeting  in  Washington  on 
May  I,  1 90 1,  the  majority  of  my  patients  had 
been  dispensary  cases,  saleswomen,  house- 
maids, hard-working  housewives,  and  some  men 
of  the  working  class. 

In  one  case  of  floating  kidney,  after  the  plas- 
ter had  been  borne  for  only  six  weeks,  I  ob- 
served, for  months  after  the  relief  had  been 
found  permanent,  that  the  relaxation  of  the  or- 
[89] 


ATOXIA   GASTRICA 


gans  or  the  ligaments  suspending  the  organs, 
together  with  the  relaxation  of  the  abdominal 
wall,  was  no  longer  perceptible;  such  was,  at 
least,  the  case  when  I   saw  the  patient  last,  six 

months  after  the  plaster  had  been  removed. 

I  give  now  the  cases  which  were  described 
at  the  above-mentioned  meeting  of  the  Ameri- 
can Gastro-Enterological  Association. 

I.  S ,  2^  years  of  age,  saleswoman.     Had 

had  cerebrospinal  meningitis,  gastroptosia  and 
nephroptosia,  anteversion,  descensus  of  ovaries, 
gastralgia,  hyperacidity,  periostitis  of  one  of 
the  spinous  processes  of  the  lumbar  vertebrae, 
and  fainting  spells.  It  is  true  she  was  sub- 
jected at  once  to  treatment  of  the  uterine  dis- 
order, the  periostitis,  and  her  enfeebled  condi- 
tion in  general,  but  the  principal  and  decided 
relief,  without  which  all  other  treatment  might 
have  been  of  little  effect,  was  given  by  strap- 
ping. Far  be  it  from  me  to  say  that  the  strap- 
ping alone  is  a  cure-all  in  cases  of  gastroptosia, 
but  it  is  by  all  means  the  most  essential  in  all 
aggravated  cases  thereof. 

In  one  case  of  heart  disease  complicated  with 
gastroptosia,  which  I  had  under  obser\-ation  for 

[90] 


A   NEW  METHOD   OF  TREATMENT 

two  years,  I  attribute  the  most  excellent  re- 
sults, the  marked  improvement  of  the  general 
condition,  to  the  strapping,  because,  from  the 
time  of  the  first  strapping,  my  patient  was  able 
to  eat  and  to  digest  as  he  had  not  been  able  to 
do  before,  in  spite  of  all  medical  and  hygienic 
measures  applied  to  him. 

In  one  case,  a  young  girl  with  gastroptosia 
was  subject  to  fainting  spells  several  times 
every  day.  The  plaster  was  applied  in  the 
clinic  of  the  Post-Graduate.  No  other  treat- 
ment was  resorted  to  until  I  had  had  an  oppor- 
tunity to  examine  the  contents  of  the  stomach. 
When  she  came,  after  having  borne  the  strap- 
ping for  one  week,  she  reported  that  her  gen- 
eral condition  had  much  improved  and  that  she 
had  not  had  her  habitual  fainting  spells.  The 
examination  of  the  contents  of  the  stomach 
showed  achylia.  In  this  and  other  cases  of 
women  we  have  to  make  allowance  for  the  exis- 
tence of  hysteria;  but  even  so,  relief  of  the 
gastroptosia  can  not  be  of  less  importance. 

On  the  whole,  in  looking  up  my  records,  I 
come  to  the  conclusion  that  strapping  is  of 
[91] 


ATONIA   GASTRICA 


great  service  and  gives  prompt  relief  in  all 
cases  of  gastroptosia  of  high  degree;  it  is  espe- 
cially valuable  where  there  are  complications 
of  lung,  heart,  or  uterine  diseases. 

A  case  which  in  my  opinion  is  important  is 
the  following : 

J.  M ,  a  boy  5  years  of  age,  was  brought 

to  my  office  October  10,  1900.  Poor  appetite, 
lives  on  bread  and  butter  and  water;  abso- 
lutely no  other  food.  Has  much  nausea  and 
vomiting,  pain  after  eating,  and  frequently  diar- 
rhea. Enuresis  nocturna  diurnaque.  Is  an 
exceedingly  nervous  child,  very  excitable  in 
playing  with  brother  and  sister.  Well-pro- 
nounced gastroptosia.  Ordered  strychnin  and 
iron,  ablution  of  the  whole  body  with  the  damp, 
ice-cold  sponge.  October  2g. — No  improve- 
ment. November  14. — Still  eats  nothing  but 
bread  and  butter,  but  a  little  more  than  former- 
ly. Bowels  now  regular.  Enuresis  nocturna 
less.  March  ig. — Appetite  still  poor,  but  has 
learned  to  drink  milk.  Enuresis  nocturna  di- 
urnaque still  continues.  Apply  rubber-plaster 
bandage.  March  2^. — The  bandage  has  re- 
mained well  in  place  and  has  given  no  dis- 
comfort. The  general  nervous  condition  has 
[92] 


A  NEW  METHOD   OF  TREATMENT 

greatly  improved ;  he  is  no  longer  irritable  in 
playing  with  other  children,  as  he  used  to  be. 
Now  eats  everything,  even  apples  and  bacon, 
altho  the  former  caused  a  slight  diarrhea. 
Enuresis  nocturna  now  rare;  diuma  still  ex- 
ists.    Case  yet  under  observation. 

I  have  never  seen  the  child  since  I  described 
the  case,  but  I  learn  through  members  of  his 
family  that  he  has  entirely  recovered  from  all 
his  ailments. 

How  well  the  plaster  is  borne  was  shown  by 
the  case  of  a  lady  in  the  higher  walks  of  soci- 
ety, to  whom  I  had  applied  't  to  relieve  gastral- 
gia  remaining  after  a  rest  cure  for  gastric  ulcer. 
This  patient  wore  her  plaster  bandage  for  over 
five  weeks,  during  which  time  she  took  her  ac- 
customed daily  bath.  When  I  removed  the 
plaster,  after  this  period  of  five  weeks,  the  skin 
was  found  in  perfect  condition. 

How  the  strapping  is  borne  under  extraor- 
dinary circumstances  was  demonstrated  in  the 
case  of  an  acrobat  who  performed  with  heavy 
iron  bars  in  a  variety  theater.  Notwithstand- 
ing his  muscular  strength,  he  suffered  from 
[93] 


ATONIA   GASTRICA 


gastroptosia  and  complained  especially  of  reflex 
vomiting.  He  was  able  to  perform  with  the 
plaster  on,  and  obtained  relief  from  his  dis- 
tressing symptoms.  I  lost  sight  of  him.  He 
belonged  to  a  company  on  the  road,  a  one- 
night  stand,  but  I  learned  from  the  druggist 
who  had  sold  him  the  plaster  that  he  had  writ- 
ten from  some  distant  place  for  another  supply. 

Dr.  Clemm  reports  the  case  of  a  directress 
of  a  ladies'  orchestra  who  played  the  first  vio- 
lin. The  active  exertion  necessitated  by  the 
vocation  of  this  woman  makes  her  case  in  a 
certain  measure  parallel  with  that  of  this  acro- 
bat. Dr.  Clemm  lost  sight  of  his  patient  as  I 
did  of  mine,  and  therefore  does  not  know  how 
long  the  improvement  has  lasted,  but  he  was 
informed  at  intervals  that  this  patient  herself 
or  some  one  of  her  company  had  afterward  ap- 
plied the  simple  contrivance. 

In  the  paper  of  May  i,  1901,  I  made  the  fol- 
lowing remarks,  which  may  prove  of  interest  at 
the  present  time  when  the  method  of  strapping 
has  become  extensively  adopted  : 

"  It  is  not  my  intention  to  give  detailed  ex- 
[94] 


A   NEW  METHOD   OF  TREATMENT 

amples  in  this  paper.  The  principle  of  the 
method  of  strapping  recommends  itself  without 
such  examples.  All  I  have  to  say  is  that  my 
experience  has  demonstrated  that  strapping,  in 
almost  all  cases,  is  well  borne,  is  enthusiasti- 
cally appreciated  by  the  patients,  and,  altho  it 
has  to  be  renewed  in  some  cases,  is  invariably 
of  permanent  benefit.  It  is  to  be  hoped  that 
this  method  will  at  least  be  given  a  chance  in 
cases  of  floating  kidney  before  they  are  deliv- 
ered over  to  the  operative  procedure  of  the 
zealous  surgeon.  .  .  .  Gastroptosia  is  much 
oftener  overlooked  than  diagnosticated.  Even 
in  papers  on  diseases  of  the  stomach  we  notice 
quite  frequently  that  all  attention  is  given  to 
secretion,  to  the  chemistry  of  the  stomach ;  the 
motor  functions,  which  should  be  considered 
the  most  important  of  all,  come  second;  the 
position  of  the  organ  is  seldom  mentioned;  of 
the  relaxation  of  the  stomach  manifested  by  the 
presence  of  splashing  sound  on  tapping  on  the 
abdomen,  or  of  the  absence  of  this  important 
symptom,  not  a  word  is  said,  altho  this  atony 
may  be  the  cause  of  or  be  connected  with  the 
[95] 


ATONIA   GASTRICA 


anomalies  of  secretion,  with  gastric  disorders 
in  general,  with  nervous  symptoms,  and  in  heart 
and  lung  affections  it  may  be  of  great  impor- 
tance." 

Almost  simultaneously  with  me,  but  inde- 
pendently— that  is,  without  knowing  of  my  ob- 
servations— Dr.  N.  Rosewater,  of  Cleveland, 
Ohio,  demonstrated,  before  the  Cleveland  Medi- 
cal Society,  February,  1900,  a  similar  method 
of  strapping  in  case  of  atonia  gastrica.  This 
paper  was  published  in  the  Cleveland  Journal 
of  Medicine,  June,  1900.  The  first  case  he 
treated  dates  from  the  year  1 898  and  is  the  fol- 
lowing : 

"In  April,  1898,  I   examined  Pearl  G , 

aged  7  years,  who  up  to  that  time  had  not  been 
able  to  speak.  The  only  sound  she  uttered  was 
a  guttural  'g.'  Other  physicians  told  the 
mother  nothing  could  be  done,  perhaps  it  would 
pass  away  in  time.  Examination  of  her  mouth 
revealed  a  normal  palate,  enlarged  tonsils,  and 
a  very  much  hypertrophied,  ragged  tongue. 
Altho  not  tongue-tied,  it  could  not  be  pro- 
truded. This  was  sufficient  cause  for  a  lack  of 
[96] 


A  NEW   METHOD   OF  TREATMENT 

articulation.  Her  hands  and  feet  were  cold 
and  clammy.  On  standing  erect  there  was  con- 
siderable protrusion,  breadth,  and  tenseness  of 
abdomen ;  the  costal  arch  was  very  wide,  as  if 
it  had  yielded  to  the  force  of  the  protruding 
abdomen.  The  left  kidney  floated  in  the  left 
iliac  fossa,  while  the  right  kidney  was  palpable 
on  deep  inspiration.  There  was  also  a  gastrop- 
tosia.  I  called  the  attention  of  my  colleague, 
Dr.  Feil,  to  this  rare  condition,  and  proceeded 
to  slip  the  left  kidney  up  into  its  place  and  to 
correct  the  abdominal  ptosis  by  a  series  of 
bandages  to  be  described  later.  This  child 
was  also  suffering  from  incontinence  of  urine, 
both  day  and  night.  She  always  slept  with  her 
mouth  open.  I  told  Dr.  Feil  at  that  time  that 
I  suspected  a  causal  relation  between  the  en- 
larged tongue  and  the  enteroptosia,  and  perhaps 
a  correction  of  this  condition  ought  to  bring 
about  some  correction  of  the  tongue.  No  med- 
icine was  to  be  given  in  this  case, 

"  I  regret  not  having  photographed  the  con- 
dition, but  hardly  expected  to  obtain  so  perfect 
a  result.      The  bandaging  was  done  as  follows  : 
7  [97] 


AtONIA  GASTRICA 


With  the  child  supine,  first  one  strip  of  two- 
inch  perforated  rubber  adhesive  was  fastened  at 
one  end  to  the  lower  part  of  the  abdomen,  a 
little  above  the  pubic  bone,  the  belly  pushed 
up,  while  traction  was  maintained  till  the  other 
end  of  the  adhesive  strip  was  fastened  to  the 
sternum ;  another  strip  attached  diagonally  on 
the  left  side  by  one  end  just  above  Poupart's 
ligament,  and  traction  made  diagonally  outward 
attaching  the  distal  end  upon  the  ribs  on  the 
back;  another  strip  correspondingly  attached 
on  the  right  side ;  finally  a  strip  three  inches 
wide  attached  from  hip  to  hip  across  the  abdo- 
men above  the  pubes  as  a  belt.  This  aid  to 
the  natural  anchorage  of  the  abdominal  muscles 
upon  their  bony  framework  furnishes  physio- 
logic rest  and  support  to  weak  muscles,  to  or- 
gans dragged  or  pressed  upon,  to  blood-  and 
lymph-vessels,  and  to  nerves  and  ligaments  out 
of  normal  tone  and  function  from  the  constant 
irritating  drag.  On  May  14,  three  weeks  later, 
the  mother  reported  that  the  child  could  make 
herself  understood  somewhat,  could  play  much 
longer,  and  did  not  get  tired  and  out  of  breath 
[98] 


A   NEW   METHOD   OF  TREATMENT 

so  easily.  She  slept  with  her  mouth  shut.  The 
bandages  were  renewed  on  June  19.  She 
could  breathe  through  her  nose  all  the  time 
and  could  pronounce  words.  Everybody  no- 
ticed that  her  speech  improved  very  much. 
Her  hands,  body,  and  feet  were  warmer  and 
dry.  On  September  ill  was  called  hastily  to 
see  her  at  her  home.  Her  mother  said :  *  Pearl 
is  suffering  from  inflammatory  rheumatism  and 
her  left  hip  pains  her  terribly.  I  can't  move 
or  touch  the  child  without  her  screaming  for 
pain.'  She  and  her  sister  had  been  out  the 
day  before  for  a  long  walk.  I  found  the  pain 
exquisite  at  the  hip  and  knee.  The  bandages 
had  come  off  before  the  girls  took  the  long 
walk.  There  was  no  redness  or  swelling  of  the 
joint  and  her  temperature  was  normal.  Suspi- 
cion fell  on  the  floating  kidney,  which  I  found 
had  slipped  under  Poupart's  ligament  and  was 
probably  pressing  upon  the  anterior  crural 
nerve.  I  slipped  the  kidney  back  into  its 
place  and  rebandaged.  Fifteen  minutes  later 
the  child  was  on  its  feet  playing  as  usual. 
"  Speech  was  fully  established  nine  months 
[99] 


ATONIA  GASTRICA 


from  first  bandaging  and  has  been  constantly 
improving  in  quality  and  rapidity  of  articula- 
tion. Bandages  were  left  off  last  June  and 
were  not  replaced  during  the  long  vacation. 
I  examined  her  repeatedly  under  deep  breath- 
ing, erect  and  on  lying  down,  but  found  the 
kidneys  were  not  palpable.  The  child  has 
growdi  stout,  and  her  hands  and  feet  are  warm 
and  dry.  Incontinence  of  urine  ceased  at  once 
and  has  not  returned  since  bandaging  first  be- 
gan. The  stomach  is  still  prolapesd,  tho  she 
eats  more  than  ever. 

"After  I  had  replaced  her  left  kidney  and 
kept  it  in  its  place  with  the  bandages  as  de- 
scribed, I  kept  her  under  my  observation  for 
over  two  years  and  found  it  always  held  in 
place.  She  was  in  my  office  only  a  few  days 
before  the  event  about  to  be  narrated,  and  was 
examined  by  both  Dr.  W.  G.  Stern  and  myself; 
the  kidney  was  then  in  place.  October  9, 
1900,  she  came  to  see  me,  complaining  of  pain 
in  her  left  inguinal  region.  It  seems  that  on 
that  day  her  teacher  had  not  permitted  her  to 

leave  the  classroom.     Before  she  had  time  to 
[100] 


A   NEW  METHOD   OF  TREATMENT 

empty  her  bladder,  she  was  seized  with  sudden 
pain  and  felt  something  give  way.  I  found  her 
right  kidney  prolapsed  and  left  kidney  floating 
again,  and,  replacing,  I  bandaged  as  before. 
Up  to  this  date.  May  20,  1901,  I  find  it  is  still 
in  place  and  neither  kidney  palpable  on  deep 
inspiration. 

"  The  overweighted  bladder  had  likely  made 
sufficient  traction  on  the  left  ureter,  either 
alone  or  aided  by  a  full  pelvis,  to  drag  the  kid- 
ney down.  This  case  emphasizes  the  necessity 
for  teachers  to  be  made  aware  of  the  possible  in- 
juries resulting  from  refusal  to  allow  attention  to 
the  demands  of  nature  in  a  reasonable  time." 

Rose  water's  Abdominal  Plaster  Strapping. 
— Rosewater,  as  do  all  other  authors,  pushes 
the  abdominal  viscera  upward.  In  case  of  ex- 
treme relaxation  or  full  habit,  in  Landau  cases, 
it  is  my  practise  to  apply  the  side-pieces  first, 
as  mentioned  and  shown  in  plate  V.  ;  this  an- 
swers best  and  most  conveniently  the  purpose 
of  pushing  up  the  abdominal  viscera  before  the 
main  piece  is  applied. 

Rosewater  places  a  plaster  strip  vertically  from 
[loi] 


ATONIA   GASTRICA 


the  symphysis  to  the  sternum  (Fig.  I.,  i,  Plate 
VIII.),  adds  two  other  strips  (Fig.  I.,  2,  3,  Plate 
VIII.),  extending  from  the  symphysis  obliquely 
sideways  and  upward  over  the  abdomen,  crossing 
each  other  on  the  back  (Fig.  II.,  2,  3,  Plate  VIII. ), 
and  finally  making  a  circular  turn  (Figs.  III., 
IV.,  4,  Plate  VIII.).  There  are  also  pieces  ap- 
plied to  cover  all  strip  ends,  a  total  of  eight  dif- 
ferent pieces. 

The  Rosewater  Adhesive  Belt. — With  the 
patient  flat  upon  his  back,  a  sufficient  length  of 
two  to  three  inches  wide  zinc  oxid  adhesive 
plaster  is  fastened  at  its  one  end  to  the  abdo- 
men just  above  the  pubes,  then  the  abdomen  is 
pushed  up  while  sufficient  traction  is  maintained 
upon  the  adhesive  plaster  until  the  other  end  is 
fastened  upon  the  sternum  parallel  to  it  and 
strongly  supporting  the  recti  muscles.  A  sim- 
ilar strip  is  attached  diagonally,  the  first  end  to 
the  left  of,  adherent  to,  and  lapping  over  the 
pubic  end  of  the  first  strip,  while  maintaining 
traction  upon  the  abdomen  and  extending  di- 
agonally to  the  left,  upward  and  outward  so  as 
to  fasten  the  strip  smoothly  over  the  ribs  as  far 

[102] 


A   NEW  METHOD   OF  TREATMENT 

back  as  the  spine.  Upon  the  right  side  a  simi- 
lar strip  is  attached  under  similar  abdominal 
traction  to  the  right,  and  its  distal  end  is  made 
to  meet  and  overlap  the  end  from  the  left  side, 
forming  a  single  diagonally  drawn  girdle  that 
completely  overcomes  the  downward  and  for- 
ward abdominal  drag,  forming  a  strong  support 
to  the  oblique  and  spinal  muscles.  A  last  piece 
of  plaster  is  fastened  by  one  end  upon  one  hip 
and  stretched  horizontally  across  the  abdomen 
so  that  its  lower  margin  is  just  above  thepubes, 
and  the  whole  in  crossing  overlaps  and  fastens 
down  the  lower  ends  of  all  the  other  strips, 
while  the  distal  end  is  firmly  fastened  to  the 
opposite  hip,  acting  as  an  additional  girdle,  pre- 
venting still  more  securely  some  of  the  down- 
ward and  forward  abdominal  drag  which  is  not 
always  possible  without  it,  and  distributing 
upon  the  strong  hip  bones  much  of  the  abdom- 
inal weight,  acting  as  a  relief  to  the  weak  spine, 
the  whole  furnishing  physiological  rest  and  tone 
to  the  failing  anatomical  wall,  to  weak  muscles, 
to  organs  dragged  or  pressed  upon,  to  nerves 
and  ligaments  out  of  tone,  nourishment,  and 
[103] 


ATONIA   GASTRICA 


function  from  constant  drag  or  pressure,  restor- 
ing overstretched  (therefore  stenosed)  blood-  and 
lymph-vessels,  both  of  the  abdominal  wall  and 
deeper  structures,  to  their  normal  caliber. 

This  method  I  have  used  with  variations  to 
suit  individual  cases  or  to  test  various  plans  and 
material,  but  the  above  is  suggestive  of  the 
principles  involved. 

The  perpendicular  strip  in  some  cases  can  be 
left  off  or  used  with  only  the  horizontal  cross 
strip,  especially  with  children.  When  there  are 
stomach  or  other  left-sided  displacements  or  in 
cases  of  perigastritis  or  other  inflammatory  con- 
ditions, especially  with  adhesions,  an  extra  diag- 
onal strip  on  the  left  side  may  be  added.  With 
hepatic  or  right-kidney  displacements,  or  in- 
flammatory conditions  of  the  right  side,  I  sup- 
port more  toward  the  right.  Instead  of  the 
single  lowest  horizontal  strip,  I  often  prefer 
two  centrally  overlapping  halves,  drawing  each 
slightly  upward  and  outward;  it  is  better  for 
heavy  abdomens,  and  the  strips  fit  with  greater 
nicety  over  the  hips.  By  previously  bathing 
the  skin  with  two-per-cent.  aqueous  borax  solu- 
[104] 


A   NEW   METHOD   OF  TREATMENT 

tion  or  with  ether,  itching  is  much  lessened. 
Any  adherent  stickiness  after  removal  of  the 
belt  can  be  cleaned  with  gasolin  or  ether  or  by 
softening  with  petrolatum  or  bland  oil  prior  to 
a  hot  bath.  The  belt  should  be  renewed  in 
two  weeks ;  never  give  consent  to  its  remaining 
over  six  weeks  for  fear  of  irritation,  even  sup- 
puration.    Shave  off  hair  if  in  way  of  plaster. 

Over  the  excellent  adhesive  belt  of  Dr.  Rose 
mine  has  greater  range  of  adaptability  to  vary- 
ing conditions,  handiness  for  bedside  use,  also 
greater  surface  of  integument  left  bare  with- 
out loss  of  utility.  Dr.  B.  Schmitz's  single  en- 
circling strip  corresponds  to  my  two  diagonal 
strips,  which  when  they  unite  in  the  back  form 
one  girdle  like  his ;  but  the  two  separate  strips 
seem  to  lift  and  support  the  abdomen  better 
from  below  upward  and  outward  than  his  sin- 
gle strip,  which  traverses  up  one  side,  following 
the  proper  direction  for  lifting  and  supporting, 
and  then  down  on  the  other  side  in  the  opposite 
direction  to  the  proper  lines  for  lifting  and  sup- 
porting, seeming  hardly  likely  to  support  as 
firmly,  and  also  seeming  more  difficult  to  put 
[105] 


ATONIA   GASTRICA 


on  except  the  patient  be  almost  nude,  whereas 
my  separate  strip,  besides  supporting  correctly, 
can  be  nicely  applied  even  when  the  clothes 
are  only  loosened. 

The  advantage  of  the  horizontal  strip  is  quite 
important,  especially  for  the  obese,  and  is  pro- 
tective about  the  easily  ruptured  groin,  for  this, 
the  lowest  point,  is  that  of  greatest  downward 
pressure. 

I  have  sometimes,  where  the  adhesive  quality 
of  the  plaster  was  poor,  put  on  small  strips 
overlapping  the  ends  at  right  angles,  to  make 
them  hold  the  ends  down  and  last  longer.  I 
also  cut  the  front  ends  of  the  diagonal  strip, 
also  the  top  of  the  first  strip,  on  the  bias  for 
cosmetic  reasons.  In  laying  the  plaster  over 
excoriated  or  irritated  surfaces  I  place  a  layer 
of  paper  or  cloth  under  the  plaster  where  it 
passes  over  such  a  surface.  I  found  several 
years  ago  after  comparison  of  the  same  make 
and  quality  of  plaster  a  decided  preference  in 
favor  of  the  non-perforated  plaster. 

The  advantages  of  the  adhesive  belt  are  adapt- 
ability to  individual  cases,  ease  of  securing  a 
[io6] 


A   NEW   METHOD   OF  TREATMENT 

perfect  fit  whether  at  the  office  or  bedside,  not 
being  subject,  as  the  removable  belts  and  corsets 
are,  to  the  caprice,  error,  loss  of  time,  and  short- 
comings of  the  instrument-maker,  also  to  the  for- 
getfulness  or  neglect  of  the  wearer  to  put  it  on 
daily  or  of  incorrectly  putting  it  on.  The  ad- 
hesive belt  is  sure  to  be  sticking  to  the  patient 
just  as  and  when  the  physician  wants  it,  day 
and  night,  and  is  firmly  held  in  any  position 
whether  of  great  strain  or  not.  It  is  the  only 
satisfactory  method  of  lifting  and  supporting 
the  flat-bellied,  and  is  elegantly  adaptable  for 
the  corpulent,  while  they  require  the  strongest 
possible  upward  lift  and  support.  After  tone 
has  been  established  in  the  organs  and  muscles, 
corpulent  patients  can  use  the  movable  belts  for 
support  and  to  prevent  return  of  the  atony,  and 
the  movable  belt  can  be  worn  where  extreme 
hairiness  or  irritated  skin  prevents  the  use  of 
the  adhesive  belt. 

The  question  whether  the  stomach   can  be 
lifted  up  by  this  procedure  can  be  easily  de- 
cided   by   mapping   out    its    upper   and    lower 
borders    before   and    directly   after  bandaging. 
[107] 


ATONIA  GASTRICA 


Both  borders  can  be  easily  demonstrated  to  have 
risen  in  most  cases  one  inch  or  more.  If  there 
are  exceptions  it  is  in  those  who  have  had  lapa- 
rotomies, usually  fixation  operations,  or  perito- 
nitis, where  adhesions  seem  to  interfere  with 
the  lifting  up  of  the  abdominal  contents. 

There  are  some  who  have  a  misconception 
that  the  abdominal  muscles  thus  supported  will 
thereafter  always  require  such  support,  and  that 
muscular  atrophy  will  follow  from  the  pressure 
and  lack  of  function.  Were  these  muscles  en- 
cased in  a  plaster-of-Paris  cast  or  in  a  non- 
pliable  corset,  and  not  at  all  used,  such  reason- 
ing might  be  plausible,  but  these  muscles  are 
just  as  pliable  and  kept  in  good  function  and 
tone  during  the  time  the  belt  is  worn,  the  ad- 
hesive belt  simply  assisting  muscles  below  nor- 
mal tone,  acting  rather  as  a  constant  tonic  of 
correct  dosage,  and  is  always  at  hand.  As  one 
instance  of  a  prolonged  tonic  effect,  an  over- 
corpulent  hard-working  woman  comes  once  an- 
nually to  have  a  bandage  applied,  which  she 
wears  about  two  months,  and  this,  she  claims, 

keeps  her  strong  the  rest  of  the  year.     Another 
[108] 


A   NEW   METHOD   OF  TREATMENT 

is  a  patient  with  lordosis,  gastroptosia,  and  ex- 
tremely sensitive  spinal  muscles,  who  for  over 
two  years  had  a  new  adhesive  belt  applied  as 
fast  as  the  old  one  was  taken  off,  the  belt  en- 
tirely encasing  her  abdomen  and  muscles  of  the 
back ;  she  continued  to  gain  in  health,  weight, 
and  strength  till  discharged  cured.  For  over  a 
year  she  has  remained  well  and  not  required  a 
belt  of  any  kind. 

Indications  for  its  use  as  a  tonic  begin  when 
a  diagnosis  of  atonia  gastrica  is  made  or  even 
anticipated,  as,  for  instance,  the  overcorpulent 
workingwoman  cited  above. 

The  adhesive  belt  is  less  important  in  those 
early  cases  in  which  the  cause  of  the  atony  is 
some  slight  hygienic  error,  such  as  overwork, 
lack  of  sleep,  or  some  sudden  shock  which  need 
not  recur  or  is  correctable  by  well-known  means  ; 
but  when  the  exciting  cause  is  constant  or  in- 
termittent or  unavoidable,  as  from  continuous 
overwork  or  occasionally  repeated  muscular  over- 
strain, or  from  anemia,  lithemia,  syphilis,  rachi- 
tis, etc.,  the  adhesive  belt  is  indicated  early,  to 
avoid  the  otherwise  constantly  increasing  atonia. 
[109] 


ATONIA   GASTRICA 


For  Gastroptosia. — When  a  demonstrable 
gastroptosia  has  finally  resulted  some  form  of 
bandage  is  indicated  to  lift  and  support  the  ab- 
dominal wall  and  its  contents,  so  that  it  and  all 
the  organs  and  vessels  can  properly  functionate. 
The  adhesive  belt  having  the  greatest  range 
of  adaptability  for  lifting  and  supporting  prop- 
erly is  especially  indicated.  After  correction 
of  the  ptosis,  to  prevent  a  recurrence  a  movable 
belt  or  properly  fitted  corset  may  answer.  It 
is  often  for  the  sequelae  of  the  visceral  ptosis 
that  relief  is  sought  as  follows : 

Circulatory  disturbances,  resulting  from  the 
drag  upon  the  abdominal  vessels,  both  super- 
ficial and  deep,  with  consequent  narrowing  of 
caliber,  require  increased  cardiac  impulse  to 
overcome  and  produce  the  normal  flow  to  the 
parts  they  feed;  the  heart  must  accordingly 
pump  with  that  much  greater  force  into  the 
cranial  and  thoracic  cavities  than  these  parts 
require,  causing  relatively  increased  general  or 
local  congestion  in  these  cavities,  as  witnessed 
by  throbbing  headaches,  conjunctival  conges- 
tion and  other  eye  disturbances,  bulging,  con- 

[IIO] 


A   NEW   METHOD   OF  TREATMENT 

gested  tonsils,  thick  and  enlarged  tongue,  and 
also  goiters,  which  disappear  after  applying  the 
adhesive  belt.  In  fact,  so  constantly  do  I  find 
goiter  and  gastroptosia  associated  that  I  venture 
to  make  a  diagnosis  of  gastroptosia  upon  evi- 
dence of  goiter. 

Cardiac  Indications. — The  heart,  finally  em- 
barrassed by  the  above-described  overwork  as 
evidenced  by  missed  beats  and  rapid  also  irreg- 
gular  action,  will  often  (even  while  we  are  still 
at  the  bedside)  regain  its  tone  and  even  im- 
prove its  rate  and  rhythm  directly  after  the  ad- 
hesive belt  is  applied. 

In  one  case  with  leaky  heart  valves,  extreme 
dropsy  of  the  extremities,  air  hunger,  continued 
sleeplessness,  and  cherry-colored  sputum,  all 
indicating  intense  thoracic  and  cranial  conges- 
tion, after  the  adhesive  belt  was  applied,  the 
legs  elevated,  and  nothing  else  given,  the  pa- 
tient passed  nearly  three  gallons  of  urine  in 
twenty-four  hours  and  slept  comfortably  on  his 
back.  It  is  only  after  the  belt  is  applied  in  such 
cases  and  the  blood-paths  are  opened  up  and 

made  uniform  that  heart  tonics  and  stimulants, 

[III] 


Atonia  gastrica 


such  as  digitalis,  strychnin,  etc.,  can  do  their 
work  properly ;  for  if  given  without  first  releas- 
ing the  drag  or  pressure  on  the  blood-vessels, 
they  simply  increase  the  congestion  of  the  part 
above  the  relatively  stenosed  vessels  in  trying 
to  force  an  adequate  blood- supply  through  them. 
Thus  constipation,  by  closing  up  the  blood-paths 
in  the  intestines,  causes  throbbing  headaches 
and  cranial  and  thoracic  congestion  by  forcing 
the  heart  to  greater  impulse  through  its  impeded 
vessels,  while  rapid  relief  of  the  constipation 
thus  rapidly  relieves  both  headaches  and  result- 
ant congestion. 

Pulmonary  Indications. — An  adhesive  belt 
is  often  indicated  in  congestions  and  inflamma- 
tions of  the  thoracic  cavity,  such  as  bronchitis 
and  pneumonia,  also  pleurisy  in  obese  or  debil- 
itated subjects,  and  in  those  in  whom  coughing 
is  painful,  distressing,  or  seems  to  injure  the  ab- 
dominal parietes,  or  causes  involuntary  mictu- 
rition. The  adhesive  belt  enables  them  to  roll 
and  toss  in  bed  with  far  more  ease  and  comfort, 
and  is  a  great  support  during  convalescence. 

I  have  found  it  of  great  help  in  pertussis.     In 

[112] 


A   NEW   METHOD   OF  TREATMENT 

one  case  (five  years  ago)  in  which  constant  vomit- 
ing threatened  the  life  of  a  six-year-old  child, 
vomiting  at  once  ceased  and  recovery  was  rapid. 
Dr.  Kilmer  has  lately  reported  similar  results 
in  a  large  number  of  cases  from  a  cloth  bandage 
much  more  troublesome  to  make  and  also  to 
stay  on  children  (except  perhaps  on  infants) 
than  the  adhesive  belt. 

Gastro-intestinal  Indications.  —  Were  a 
work  on  gastro-intestinal  diseases  to  be  written 
to-day  by  one  not  hampered  by  past  traditions, 
a  revolution  in  the  presentation  of  the  entire 
subject  would  occur.  A  small  amount  of  space 
would  be  devoted  to  the  findings  of  the  stomach 
contents  except  as  data  of  corroboration  of  the 
functional  symptoms,  whereas  by  far  the  great- 
est part  would  be  given  to  causes  leading  to  the 
deteriorated  function  of  the  digestion  tract,  not 
the  least  of  which  is  atonia  gastrica.  Were  such 
a  man  to  lecture  to  a  class  of  medical  students 
he  would  dwell,  not  so  much  upon  the  rarer 
conditions  of  a  cancer,  ulcer,  or  chronic  fermenta- 
tive disturbance,  which  the  average  medical  man 
will  not  see  more  than  once  or  twice  a  year, 
8  [113] 


ATOXIA   GASTRIC  A 


but  rather  upon  the  more  common  condition  of 
almost  every-day  practise — gastroptosia.  Gas- 
tro-intestinal  diseases  ensue  as  secondary  results 
of  visceral  ptosis  far  oftener  than  as  primary 
affections.  The  adhesive  belt  is  here  espe- 
cially indicated.  A  test  meal  in  these  cases  is 
useless  for  treatment  and  only  useful  as  a  mat- 
ter of  record.  When  the  ptosis  has  been  cor- 
rected usually  the  functional  condition  returns 
to  normal,  so  that  only  then  can  we  obtain  find- 
ings by  the  test  meal  which  will  be  constant, 
whereas  treatment  of  the  functional  condition 
is  only  temporizing.  This  applies  equally  to 
superacidity  or  subacidit}",  to  mucous  catarrhs, 
fermentative  conditions,  intestinal  indigestions, 
acute  or  chronic  diarrheas,  constipations  and 
those  alternating  with  diarrheas.  The  remark- 
ably rapid  results  from  the  adhesive  belt  have  de- 
monstrated that  the  ptosis  and  atonic  state  of  the 
parts  involved  act  more  often  as  causative  than 
as  resultant  factors,  for  even  the  dilated  stom- 
ach often  results  from  ptosis  followed  by  atony 
and  dilatation.  For  ulcer  of  the  stomach,  Mayo 
(and  no  one  is  better  qualified  to  speak  than  he) 
[114] 


A  NEW  METHOD   OF  TREATMENT 

says,  "  Clinical  experience  has  taught  that  drain- 
age is  the  best  method  of  surgical  treatment. " 
In  this  we  can  all  concur,  but  by  the  aid  of  the 
adhesive  belt  the  stomach  is  so  much  more  surely 
drained  that  no  case  should  go  to  the  surgeon 
without  first  trying  the  adhesive  belt,  unless 
there  is  a  positive  stenosis  of  the  pylorus,  as  the 
following  case  will  demonstrate. 

Miss  K.  L ,  aged  25,  whom  I  first  saw  in 

Rosenheim's  clinic,  where  she  had  been  under 
treatment.  Morning  lavage  brought  up  quanti- 
ties of  food  remnants.  Symptoms  of  belching, 
burning  pain,  nausea,  and  vomiting  after  meals. 
She  had  been  treated  for  fifteen  months  in  Boas's 
clinic,  who  then  sent  her  to  the  Charity,  where 
under  von  Leyden's  care  she  remained  ten 
months,  repeatedly  refusing  operation,  finally 
leaving  there  to  come  to  Rosenheim's  clinic. 
He  after  six  weeks'  trial  was  about  to  send  her 
to  the  surgeon,  but  at  my  request,  after  the 
patient  protested,  a  trial  of  the  adhesive  belt 
was  made,  resulting  at  the  end  of  only  three 
weeks  in  disappearance  of  all  subjective  symp- 
toms and  a  gain  in  weight.  Repeated  trials 
failed  to  show  food  remnants  in  the  morning 
[115] 


ATONIA   GASTRICA 


lavage.      (Diet,  two  meals  a  day  instead  of  six 
and  seven  as  before.) 

In  chronic  perityphlitis,  perigastritis,  chole- 
cystitis, and  when  organs  are  dragged  about 
while  in  a  state  of  irritation  or  inflammation, 
the  adhesive  belt,  by  fixing  them  and  preventing 
drag,  is  a  great  aid  when  surgery  can  not  be 
used.  In  typhoid  fever,  when  there  is  an  ex- 
treme atony  and  when  everything  is  done  to 
avoid  undue  heart  action,  and  during  delirium, 
when  violent  sudden  strains  and  motion  of  the 
body  are  to  be  avoided,  the  adhesive  belt  is 
very  valuable.  Convalescents  left  their  beds 
with  new  bandages,  and  there  were  no  relapses 
or  sequelae.  What  is  true  as  to  bandaging  of 
typhoid  convalescents  applies  to  all  with  acute 
debilitating  diseases. 

Pelvic  Indications. — The  adhesive  belt  is 
indicated  for  many  pelvic  disturbances.  Incon- 
tinence of  urine  in  children  or  in  adults,  irritated 
bladder  attended  with  spasm,  also  neuralgias, 
have  yielded  often  to  abdominal  bandaging,  the 
abdominal  pressure  causing  disturbances  of  in- 
[116] 


A   NEW  METHOD   OF  TREATMENT 

nervation  and  muscular  weakness.  Ovarian 
and  uterine  conditions,  such  as  oothecalgia, 
dysmenorrhea,  and  leucorrhea  from  local  conges- 
tion, results  of  poor  circulation  caused  by  undue 
abdominal  pressure,  may  be  corrected  by  the 
adhesive  belt.  Relief  during  dysmenorrhea 
often  has  been  immediate. 

Disturbance  from  fibroids  of  the  uterus  and 
other  abdominal  tumors  when  causing  excessive 
downward  abdominal  pressure,  constant  back- 
ache, frequent  micturition,  are  relieved  by  the 
belt,  the  direction  of  support  depending  on  the 
case.  Disturbances  of  pregnancy  from  weight 
and  pressure  will  often  disappear  on  the  use  of 
the  belt  or  an  elastic  bandage.  No  woman  after 
delivery  of  the  child  should  be  allowed  to  sit  up 
without  the  adhesive  belt.  It  is  the  ideal  band- 
age for  such  cases. 

Pressure  of  the  overhanging  and  of  the  obese, 
abdomen,  in  those  who  walk  about  often,  is 
made  upon  the  vessels  of  the  groin.  I  have 
traced  local  edema,  which  the  plaster  belt 
quickly  relieves,  to  such  cases.  Also  a  neu- 
ralgia, traceable  to  a  floating  kidney  pressing 
[117] 


ATONIA   GASTRICA 


either  directly  on  a  nerve  or  on  the  vessels  of 
the  groin,  interfering  with  nerve  nutrition,  was 
relieved  at  once  on  replacement  and  bandaging. 

Obstinate  cases  of  varicose  ulcers  in  such  pa- 
tients as  have  resisted  previous  medical  treat- 
ment over  long  periods  were  invariably  cured 
when  treated  with  elevation  of  the  leg  and  the 
adhesive  belt.  In  no  case  was  the  cure  delayed 
beyond  two  weeks. 

Obstinate  eczema  and  intertrigo  due  to  hang- 
ing belly,  when  the  overlapping  surfaces  main- 
tained a  constant  irritation,  were  rapidly  re- 
lieved and  cured  after  the  overlapping  portion 
was  lifted  away  and  supported  with  plaster. 

Coxalgia  resulting  from  pressure  of  weight 
upon  a  recently  injured  coccyx,  sciatica,  and 
other  severe  pelvic  backaches  have  been  rapidly 
relieved  by  not  only  bandaging  the  heavy  abdo- 
men but  also  lifting  the  fleshy  hips  and  sup- 
porting them  upon  the  sacral  spine,  thus  taking 
off  excessive  weight. 

Spinal  lateral  curvature  with  displaced,  some- 
what twisted  organs,  manifested  by  most  excru- 
ciating suffering  at  the  menstrual  epoch,  also 
[ii8] 


A  NEW  METHOD   OF  TREATMENT 

with  severe  gastric  symptoms,  has  been  perma- 
nently relieved  of  all  subjective  symptoms  by 
lifting  and  forcing  the  organs  back  in  the  di- 
rection from  which  they  seemed  displaced,  by 
means  of  the  adhesive  belt,  maintaining  traction 
also  against  the  curvature. 

The  backaches  of  kyphosis  and  lordosis  are 
also  benefited  by  the  adhesive  belt.  The  dis- 
placed organs  (kidneys,  stomach,  transverse 
colon,  liver,  and  spleen)  can  be  lifted  and  sup- 
ported. The  kidneys  can  be  replaced  and  often 
kept  in  place  by  proper  manipulation. 

In  conclusion,  as  a  preventive  measure  all 
children  and  adults  who  have,  or  in  their  daily 
walks  or  work  are  liable  to  have,  weak  abdom- 
inal muscles  or  hernias,  all  who  labor  hard,  lift 
or  carry  heavy  burdens,  all  soldiers  and  others  in 
hot  climates,  or  those  who  make  sudden  or  long, 
exhausting  marches,  should  wear  as  a  support 
and  preventive  a  proper  girdle  or  belt  and  have 
their  abdominal  muscles  strengthened  according 
to  practicability  by  such  methods  as  electricity, 
massage,  hydriatics,  gymnastics,  etc.  Women 
should  avoid  wrongly  constructed  corsets. 
[119] 


ATONIA   GASTRICA 


Gymnastic  exercise,  especially  for  women  and 
children,  should  be  limited  to  such  motions  as  can 
not  possibly  cause  displacement  of  the  organs. 


Independently  of  Dr.  Rosewater  and  myself, 
Dr.  B.  Schmitz,  of  Wildungen,  Germany,  has 
hit  upon  a  similar  device,  but  he  had  in  view 
the  treatment  of  the  kidney  merely.  His 
method  will  be  described  in  another  chapter; 
also  the  suggestions  for  which  we  are  indebted 
to  him  in  the  adjustment  of  the  belt  in  cases 
of  inflamed  kidneys. 

Dr.  Walther  Nicolas  Clemm,  of  Darmstadt, 
introduced  into  Germany  the  method  of  abdom- 
inal strapping  for  the  support  of  the  abdominal 
viscera  in  case  of  gastroptosia,  as  suggested  by 
me.  His  first  article  on  the  subject  appeared  in 
the  Therapeutische  Monatshefte,Y€c>r\x2xy,  1903, 
and  quite  a  literature  on  the  subject  has  since 
been  created,  showing  how  much  the  device  is 
appreciated  abroad. 

Dr.  Clemm  says :  "  The  applications  of  this 
dressing  I  have  extended.  I  employ  it  in  after- 
[120] 


A   NEW  METHOD   OF  TREATMENT 

treatment  of  ulcus  ventriculi,  as  well  as  in  all 
affections  of  the  stomach  tending  to  hemor- 
rhage ;  above  all,  in  the  suppression  of  painful 
pylorus  spasm  and  also  in  after-treatment  of 
typhlitis.  In  all  these  conditions  the  same 
benefit  will  be  derived  from  the  use  of  dressing 
as  in  many  other  affections,  such,  for  instance, 
as  Schmitz  has  described  when  he  supported  not 
only  the  displaced  but  also  the  normally  situ- 
ated tho  inflamed  kidney.  I  believe,  how- 
ever, that  the  simple  abdominal  belt  is  much 
preferable  to  Schmitz's  complicated  dress- 
ing with  plasters  in  the  shape  of  straps  and 
girdles." 

The  directions  for  the  dressing  in  after-treat- 
ment of  ulcus  ventriculi  I  myself  drew  up,  soon 
after  I  began  practising  the  method.  In  gas- 
tric ulcer  we  have,  as  a  rule,  to  deal  with  the 
ulcer  itself,  which  will  cause  pain  immediately 
or  soon  after  ingestion  of  food — exactly  as  a 
sore  on  the  tongue  when  irritated  by  morsels 
of  food  introduced  into  the  mouth,  and  espe- 
cially in  the  case  of  coexisting  hyperchlorhydria. 
After  an  ulcer  cure  has  been  accomplished  and 

[121] 


ATONIA   GASTRICA 


the  characteristic  ulcer  pains  have  subsided,  we 
may  find  the  symptoms  of  hyperchlorhydria 
much  more  pronounced  than  they  were  before 
the  treatment  of  the  ulcer.  Patients,  instead 
of  having  the  characteristic  ulcer  pains — that 
is,  the  pains  that  follow  ingestion — will  com- 
plain of  the  characteristic  hyperchlorhydria 
pains  they  feel  some  hours  after  eating,  or  dur- 
ing the  night,  or  early  in  the  morning.  These 
new  pains  after  an  ulcer  cure  were  the  veri- 
table crux  of  physicians  in  former  times,  when 
the  symptoms  of  hyperchlorhydria  and  their 
treatment  by  means  of  diet  were  not  under- 
stood so  well  as  they  are  now,  when  the  regi- 
men of  Illoway — the  most  perfect  that  can  be 
imagined — was  yet  unknown.  The  text-books 
gave  no  aid;  while  they  mentioned  narcotics, 
they  gave  warnings  of  a  new  danger  to  be  in- 
curred by  their  employment,  and  confessed 
that  even  as  palliatives  they  were  of  little 
avail. 

With  the  idea  in  mind  that  pain  might  be  re- 
lieved by  means  of  equally  distributed  pressure 
on    the    whole   abdominal    wall,  and   influence 

[122] 


A   NEW   METHOD   OF   TREATMENT 

thereby  be  exercised  on  the  circulation  and  in- 
nervation of  the  abdomen,  I  applied  the  plaster 
belt  and  found  that  it  actually  answered  the 
purpose.  At  that  time  I  was  not  yet  aware 
that  abdominal  strapping  had  the  effect  of  reg- 
ulating disorders  of  gastric  secretion. 

Observations  made  in  the  treatment  of  dis- 
pensary patients  in  the  New  York  Post- Gradu- 
ate Medical  School  and  Hospital,  and  the  very 
exact  investigations  of  Dr.  C.  J.  Graham  Rog- 
ers in  Dr.  Kemp's  clinic  of  Manhattan  State 
Hospital,  Wards  Island,  have  demonstrated  the 
fact  that  there  exists  a  close  relation  between 
secretory  disorders  and  gastroptosia,  that  all 
forms  of  anomalous  gastric  secretion  may  be 
associated  with  gastroptosia,  and  that  relief 
from  anomalous  secretion  may  follow  as 
promptly  as  relief  from  motor  insufficiency 
after  gastroptosia  has  been  relieved. 

Dr.  Rogers  has  made  an  analysis  of  stomach 
contents  in  cases  in  which  the  abdominal  strap- 
ping had  been  applied.  His  report,  which  he 
read  at  a  meeting  of  the  New  York  Post-Grad- 
uate  Clinical  Society,  December  i8,  1903,  in- 
[123] 


ATONIA   GASTRICA 


stances  35  such  cases,  all  of  Dr.  Kemp's  clinic 
in  the  epileptic  ward  of  the  Manhattan  State 
Hospital,  Wards  Island.  Of  these  35  cases, 
14  were  put  on  a  special  diet.  Three  of  these 
14  had  gastroptosia,  and,  in  addition,  there  was 
hyperchlorhydria  present.  In  all  these  cases 
the  gastric  symptoms  cleared  up  after  the  ap- 
plication of  the  belt  and  subjection  to  special 
diet,  together  with  internal  medication. 

Seven  cases  of  gastroptosia  were  then  se- 
lected and  treated  with  the  belt  alone.  In  one 
of  these  there  existed  hypochlorhydria  and  in 
six  hyperchlorhydria.  In  four  of  these  marked 
improvement  followed. 

It  is  evident,  therefore,  that  the  after-treat- 
ment of  ulcus  ventricuii  by  means  of  the  ab- 
dominal plaster  belt  is  effective  in  reducing  the 
hyperacidity. 

Dr.  Clemm,  in  his  paper  "  On  Adhesive 
Plaster  Dressing  to  Support  the  Abdominal 
Viscera,"  a  translation  of  which  appeared  in 
TJie  Post- Graduate,  November,  1904,  mentions 
further,  among  the  disorders  which  he  discov- 
ered to  be  benefited  by  applying  the  belt,  all 
[124] 


A   NEW  METHOD   OF   TREATMENT 

affections  of  the  stomach  inclining  to  hemor- 
rhage. I  have  as  yet  no  experience  on  this 
point,  but  consider  Clemm's  suggestion  a  most 
rational  one.  He  speaks  likewise  of  the  meth- 
od as  being  of  service  in  the  suppression  of 
painful  pylorus  spasm.  According  to  my  own 
experience,  there  are  cases  in  which  it  will 
prove  serviceable,  and  others  in  which  the 
cause  of  the  pylorus  spasm  is  not  connected 
with  gastroptosia,  where  the  belt  can  not  be  of 
any  benefit  whatever.  He  has  recommended  it 
also  in  after-treatment  of  typhlitis.  I  wish  to 
add  that  it  is  to  be  considered  for  theoretical 
reasons  a  most  rational  prophylactic  against 
perityphlitis.  I  may  be  permitted  on  this 
occasion  to  say  that  the  barbarous  term  "  ap- 
pendicitis," so  universally  in  use,  is  about  the 
most  horrible  example  of  scientific  ignorance — 
as  Kant  calls  it,  in  contradistinction  to  ordi- 
nary ignorance — and  bad  taste. 

Clemm,   in  the  same  paper,   says :    "  I  have 

treated  with  the  belt  simple  ptosis  of  viscera 

and  have  had  more  or  less  lasting  success.     In 

a  case  of  very  obstinate  mucous  colic  and  in 

[125] 


ATONIA  GASTRlCA 


cases  of  cholelithiasis  I  found  the  abdominal 
belt  very  valuable  as  a  complementary  measure 
in  addition  to  a  method  I  have  suggested." 

Dr.  Kemp  also,  as  well  as  myself,  before  we 
knew  of  Dr.  Clemm's  experience,  found  that 
abdominal  strapping  may  be  prescribed  in  mu- 
cous colic. 

Some  distinguish  between  enteritis  mem- 
branacea — a  genuine  enteritic  catarrh — without 
colicky  pains  and  colica  mucosa,  the  latter  be- 
ing characterized  by  the  well-known  complica- 
tions of  symptoms,  chief  among  which  are  col- 
icky pains.  Nothnagel  calls  this  latter  form  a 
disease  siii  generis.  As  far  as  my  own  observa- 
tions (confirmed  by  observations  made  by 
Dr.  Kemp)  show,  mucous  colic  is  not  a  dis- 
ease sui  generis,  but  one  of  the  symptoms  of  gas- 
troptosia. 

The  question  whether  gastroptosia  is  in  all 
cases  the  cause  of  mucous  colic  must  be  decided 
by  further  observation;  but  it  is  easy  to  arrive 
at  a  decision  ex  jiivantibiis.  Thus  far  but  few 
writers  have  paid  attention  to  the  coincidence 
of  gastroptosia  with  mucous  colic.  Kemp 
[126] 


A  NEW  METHOD  OF  TREATMENT 

writes  :  *  "In  gastroptosia,  I  believe  we  have 
the  chief  etiological  factor  in  mucous  colic. 
Ewald  has  pointed  out  that  ptosis  of  the  colon 
frequently  occu'-s  simultaneously  with  this  con- 
dition, and  Einhorn  has  der^onstrated  that  gas- 
troptosia is  present  in  a  large  percentage  of 
cases  of  mucous  colic.  ,  .  .  Mucous  colic  is  not 
present  in  all  cases  of  gastroptosia,  any  more 
than  is  hemorrhage  in  all  cases  of  typhoid  fever. 
All  cases  of  mucous  colic  are  neurasthenic,  but 
all  cases  of  neurasthenia  do  not  suffer  from 
mucous  colic. 

"  On  the  other  hand,  there  must  be  a  predis- 
posing cause  both  for  the  neurasthenia  and  the 
mucous  colic,  since  these  two  constitute,  I  be- 
lieve, a  *  vicious  circle  '  and  react  on  each  other. 
I  have  indeed  been  enabled  from  my  own  expe- 
rience to  demonstrate  the  fact  that  gastroptosia 
is  an  etiological  factor  in  mucous  colic.  The 
abnormal  secretion  of  the  stomach  (as  it  occurs 
in  cases  of  gastroptosia)  undoubtedly  aggravates 
this  condition. 

*"  Observations  on  Dilatation  of  the  Stomach  and  on 
Gastroptosis."     Medical  News,  August  6,  1904. 
[127] 


ATONIA   GASTRICA 


"  To  further  substantiate  this  view  I  have 
under  observation  a  patient  with  typical  at- 
tacks of  mucous  colic,  which  began  only  two 
months  ago.  These  commenced  a  month  after 
confinement.  She  has  gastroptosia,  due  to  in- 
sufficient support  of  the  abdomen  after  the  birth 
of  her  child.  She  is  not  neurasthenic,  and  is 
only  nervous  at  the  time  of  her  attack.  This  is 
certainly  significant. 

"  It  would  seem  that  ptosis  of  the  intestines 
and  the  resulting  changes  in  the  caliber  of  the 
lumen  of  the  gut  at  various  points  fully  explain 
the  cramp-like  effort  to  expel  the  mucus  and  the 
tubular-cast  shape  of  the  mucus  which  we  see 
at  times.  Furthermore,  injections  of  olive  oil 
appear  to  relieve  the  attacks  of  colic,  just  as  it 
does  given  by  mouth  in  the  case  of  stenosis  of 
the  pylorus.  I  do  not  believe  the  mucous  dis- 
charge is  due  to  a  true  inflammatory  condition, 
but  to  changes  in  the  circulation  due  to  the  ab- 
normal position  of  the  intestines.  Where  there 
is  a  narrowing  at  one  point  there  must  of  ne- 
cessity be  a  dilatation  and  congestion  in  the  in- 
testine above  it. 

[128] 


A   NEW   METHOD    OF  TREATMENT 

"  I  believe  that  adhesions,  rectal  obstruction, 
or  irritation,  and  other  such  causes  given  by  our 
authorities,  are  merely  accessory  factors  in  the 
vicious  circle.  ...  I  invariably  apply  abdom- 
inal support  in  cases  of  mucous  colic,  and  have 
always  found  relief  therefrom." 

Thus  far  but  few  writers  have  paid  attention 
to  the  coexistence  of  gastroptosia  in  cases  of 
mucous  colic,  and  I  know  of  none,  except 
Clemm  and  Kemp,  who,  in  the  treatment  of 
mucous  colic,  have  considered  the  presence  of 
gastroptosia. 

The  first  case  of  mucous  colic  Dr.  Kemp 
treated  at  my  suggestion  with  adhesive  plaster 
strapping  was  cited  by  me  in  a  memoir  I  pub- 
lished in  The  International  Clinics  of  1903.  It 
was  that  of  a  woman  of  thirty-five  years.  I  saw 
her  by  courtesy  of  Dr.  Kemp  in  St.  Bartholo- 
mew's Clinic,  New  York,  on  December  20, 
1902.  She  had  been  passing  mucus  and  had 
had  colicky  pains  for  seven  years ;  had  gastrop- 
tosia and  suffered  also  from  hyperchlorhydria. 
The  diet  we  ordered  was  that  introduced  by 
Illoway  for  cases  of  hyperchlorhydria ;  the  ab- 
9  [129] 


ATONIA   GASTRICA 


domen  was  strapped  with  the  adhesive  plaster 
belt,  and  the  rectum  was  inflated  with  carbonic 
acid  gas.  Under  this  combined  treatment 
she  improved  continually  in  every  direction. 
From  January  2  to  January  9,  1903,  the  day 
she  was  dismissed,  she  had  passed  no  more 
mucous  strips  and  had  had  no  more  colicky 
pains. 

By  means  of  the  abdominal  strapping  science 
has  been  enabled  to  recognize  the  relation  of  a 
number  of  ailments  to  atonia  gastrica, 

Mrs.  W ,  a  lady  of  refinement,  came  to 

my  office  September  30,  1903.  She  was  32 
years  of  age,  the  mother  of  three  children,  the 
youngest  being  four  and  one-half  years.  Being 
of  excellent  physique  she  had  always  enjoyed 
good  health  until  three  years  before  I  saw  her, 
when  she  began  to  suffer  from  some  uterine 
disorder.  She  went  from  here  to  a  celebrated 
gynecologist  of  Berlin,  who  removed  one  of  the 
ovaries.  On  that  occasion  she  came  near  losing 
her  life  accidentally  from  secondary  hemor- 
rhage. Having  recovered  from  the  operation 
she  returned  to  America.  This  was  about  fifteen 
months  before  coming  to  me.  From  that  time 
[130] 


A   NEW   METHOD    OF   TREATMENT 

on  she  suffered  from  diarrhea.  As  a  rule  she  had 
from  six  to  eight  very  rapid  watery  evacuations 
daily,  the  discharges  coming  as  if  forced  from 
a  syringe.  Most  of  them  occurred  in  the  morn- 
ing before  and  after  breakfast.  She  had  to  be 
extremely  careful  in  her  diet,  knowing  by  expe- 
rience which  articles  of  food  were  likely  to  ag- 
gravate her  deplorable  condition.  During  the 
fifteen  months  she  had  consulted  many  physi- 
cians and  had  taken  much  medicine,  but,  except- 
ing some  temporary  relief,  there  had  been  no 
satisfactory  result.  Menses  are  regular  from 
four  to  five  days ;  no  dysmenorrhea.  Finding 
that  hers  was  a  case  of  gastroptosia  with  well 
pronounced  nephroptosia,  I  applied  the  belt. 
October  i,  she  had  only  four  evacuations  and 
these  were  less  watery.  Felt  stronger,  had  good 
appetite.  Ate  chicken  with  rice,  which  was  a 
dish  which  she  had  previously  excluded  from  her 
bill  of  fare  as  something  on  the  index  renim 
prohibitarum.  November  12,  she  had  worn  the 
belt  over  four  weeks.  Her  general  condition  was 
excellent.  She  ate  and  drank  with  impunity 
whatever  she  fancied,  even  sauerkraut,  and  she 
can  drink  beer  and  wine  now  as  she  had  been 
accustomed  to  do  in  former  years.  Her  bowels 
were  regular  and  normal, 
[131] 


ATONIA   GASTRICA 


I  will  not  enter  into  details  of  this  case  be- 
cause my  only  object  in  quoting  it  is  to  show 
the  prompt  and  lasting  effect  the  plaster  dress- 
ing can  exert  in  some  cases  of  enteritis,  how 
enteritis  can  be  one  of  the  symptoms  of  gas- 
troptosia,  and,  last  but  not  least,  how  the  plas- 
ter dressing  excels  all  medication  in  such  cases 
as  the  one  here  described. 

Dr.  Rosewater  in  a  letter  addressed  to  me 
writes  :  "  One  of  the  most  positive  remedies  for 
chronic  diarrhea  (or  acute  either)  is  the  abdom- 
inal strapping.  It  is  remarkable  how  little  at- 
tention I  have  had  my  patients  pay  to  the  usual 
cautions  about  diet,  when  afflicted  with  this 
trouble.  I  let  them  have  pie,  pastry  of  all  kinds 
— sauerkraut — almost  anything  ifproperly  mas- 
ticated (in  lithemia  case^  no  uric-acid  foods), 
and  they  are  astonished  at  the  fact  that  they 
have  no  trouble  whatever  with  these  popularly 
condemned  articles  of  diet.  This  idea  of  intes- 
tinal indigestion  or  fermentation  being  the  cause 
of  the  diarrhea  is  most  often  putting  the  cart 
before  the  horse,  as  we  say ;  they  are  the  results 
of  faulty  correctable  conditions.  .  .  .  No  case, 
[132] 


A   NEW  METHOD   OF   TREATMENT 

so  far,  has  failed  to  get  positive  and  permanent 
benefit.  I  suppose,  however,  a  case  of  bowel 
tuberculosis  with  ulceration  could  not  be 
cured. " 

Dr.  Mangelsdorf,*  of  Bad  Kissingen,  observed 
that  the  stomach  of  a  patient  whom  he  had  ex- 
amined the  day  previous  had  become,  during  an 
attack  of  migraine,  very  much  larger  than  on  the 
preceding  day.  Two  years  before,  the  occur- 
rence of  rapidly  passing  temporary  stomach  dil- 
atation had  been  confirmed  on  consultation  with 
a  high  authority.  Since  then  he  had  devoted 
closer  attention  to  this  phenomenon  and  in  the 
succeeding  years  observed  a  considerable  num- 
ber of  cases  which  converted  his  previous  opin- 
ion into  a  certainty,  that  every  attack  of  migraine 
is  accompanied  by  a  dilatation  of  the  stomach 
far  beyond  its  customary  borders. 

These  observations  were  made  by  subjecting 
every  migraine  patient  coming  under  treatment 
to  a  careful  examination  as  to  the  limits  of  the 

*  I  give  here  a  complete  translation  of  Dr.  Mangels- 
dorf's  paper  (Berliner  klin.  Wochenschrift,  1903,  No.  44), 
which  translation  is  taken  from  The  Post-Graduate,  Janu- 
ary, 1904. 

[133] 


ATONIA   GASTRICA 


stomach,  then  confirming  it  by  one  or  several 
examinations  while  still  free  from  an  attack,  and 
repeating  this  during  and  after  an  attack,  until 
the    stomach   had   regained  its  normal  dimen- 


FiG.  II. — Migraine,  June  19, 1902.    Borders  of  stomach;  4,  June  i:  ; 
2,  June  19,  in  the  evening;  4,  June  20,  in  the  morning. 

sions.  This  dilatation  is  symmetrical  in  all 
directions  and  contracts  in  a  corresponding- 
manner,  as  shown  by  Figs.  1 1  and  12,  not  sche- 
matically drawn  but  reduced  from  life  size  and 
illustrating  the  condition  perfectly. 
[134] 


A   NEW   METHOD    OF  TREATMENT 

Still  more  to  the  purpose  are  curves  present- 
ing in  centimeters  the  greatest  vertical  diameter 
of  the  stomach.  The  attack  illustrated  in  Fig. 
12  presented  by  the  measures  a-(J  [i],  b-b  [i], 
c-c  [i],  d-d  [i],  e-e  [i]  and  f-f  [i]  isthus 
demonstrated  as  a  curve. 


Fig.  12.— Migraine,  August  29,  1902.  Borders  of  stomach ;  i,  Au- 
gust 16;  2,  August  29,  in  the  morning;  3,  August  29,  in  the 
evening ;  i,  August  30,  in  the  morning ;  5,  August  30,  in  the 
evening  ;  6,  August  31,  in  the  morning. 

Repeated  attacks  of  migraine,  with  more  or 
less  rapid  succession  of  dilatation  and  contrac- 

[135] 


ATONIA   GASTRICA 


tion,  lead  in  the  course  of  years  to  a  permanent 
change  in  the  tonicity  of  the  stomach.  Atony 
obtains  which,  after  reaching  a  certain  degree, 
produces  disturbances  in  the  stomach  and  intes- 
tines.     These  subjective    symptoms  caused  a 


1002 

fuQlSl 

Seplembet                                              | 

n 

20 

2S 

20^0 

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2 

9 

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40  cm. 

35 

*/ll 

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1 

25 

^^^^ 

20 

^ 

a 

15 

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10 

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a 

b 

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Fig.  13. 

comparatively  large  number  of  migraine  patients 
to  apply  to  him  for  treatment.  While  this  atonic 
dilatation,  present  in  patients  at  the  inception  of 
treatment,  is  gradually  brought  back  to  normal, 
the  attacks  of  migraine  occurring  from  a  variety 
of  causes  furnish  curves,  as  illustrated  in  Fig.  14. 
If  these  figures  indicate  that  the  phenomenon 
is  more  pronounced  on  July  23  and  31  and  Au- 
gust 14  than  in  the  attack  of  June  4,  in  the  later 
[136] 


A  NEW   METHOD   OF  TREATMENT 


- 

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[137] 


ATONIA   GASTRICA 


attacks  the  absolute  distention  of  the  stomach 
is  less  than  in  the  first,  since  the  elevation  at 
the  later  dates  proceeds  from  a  different  niveau 
than  that  connected  with  the  apparently  milder 
first  attack  of  migraine.  The  actual  and  last- 
ing damage  to  the  tonicity  of  the  stomach  on 
the  whole  and  the  manner  of  its  occurrence 
are  pregnantly  demonstrated  by  such  a  curve. 


1902 

AUQust                                                                                                                      September           \ 

8 

W 

II 

12 

22 

23 

2* 

25 

26 

23 

3 

30  cm. 

25 

A 

1 

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20  ' 

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w 

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15 

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to 

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Fig.  15. 


It  is  obvious  that  migraine 
of  atony  of  the  stomach  and 
long  series  of  cases  usually 
pathic,  a  term  used  for  lack 
edge  of  their  true  origin.  It 
to  state  that  in  nearly  all 
in  which  the  stomach  could 
[138] 


is  a  frequent  cause 
makes  plausible  a 
classed  as  neuro- 
of  specific  knowl- 
suffices  at  present 
cases  of  migraine 
be  examined,  this 


A   NEW   METHOD   OF  TREATMENT 

atonic  condition  was  in  evidence.  In  469  pa- 
tients suffering  from  migraine  (150  men  and 
319  women)  observed  by  him  up  to  date — Feb- 
ruary, 1903 — it  was  possible  to  examine  the 
stomach  in  418  cases.  In  9  cases  the  limits 
could  not  be  defined,  owing  to  dense  layers  of 
adipose  tissue  and  other  causes.  Of  the  409 
remaining  cases  only  one  female  patient  had  a 
normal  stomach  and  she  was  a  young  girl  of 
fourteen,  suffering  from  migraine  but  a  short 
time.  Detailed  information  concerning  this,  as 
well  as  the  close  relations  between  migraine  and 
atony  of  the  stomach  and  intestine,  is  reserved 
for  future  publication. 

The  occurrence  of  acute  atony  of  the  stomach 
in  attacks  of  migraine  can  be  explained  only  by 
centrally  operative  causes,  at  present  quite  as 
obscure  as  migraine  itself.  Proceeding  upon 
this  assumption  he  endeavored  to  make  obser- 
vations concerning  possible  changes  i  1  the 
stomach  occurring  in  connection  with  all  sorts 
of  attacks  occurring  in  various  nervous  and 
brain  diseases.  Practise  in  an  institution  does 
not  furnish  the  best  opportunities.  Several 
[139] 


ATONIA   GASTRICA 


years  ago  Prof,  de  Von  Speyer,  of  Bern,  placed 
at  his  disposal  the  rich  material  of  the  Kan- 
tonal  Insane  Asylum.  The  findings  corre- 
sponded to  Mangelsdorf's  former  ones,  being 
entirely  negative  in  all  forms  of  diseases  except 
in  idiopathic  epilepsy.  Epileptic  attacks  pro- 
duced phenomena  strictly  analogous  with  those 
occurring  in  migraine  and  corresponding  to  those 
observed  in  epileptics  in  his  practise.  Oppor- 
tunity for  observation  in  private  practise  is  quite 
rare ;  all  the  more  reason  for  accentuating  the 
obligation  to  Medicinal-Rath  Dr.  Wuerschmidt, 
who  placed  at  his  disposal  the  epileptic  patients 
of  the  insane  asylum  at  Erlangen.  A  series  of 
observations  confirmed  the  fact  that  every  epi- 
leptic attack  noted  by  him  was  accompanied  by 
the  gastric  phenomenon  in  question. 

Given  a  relative  frequency  of  attacks,  epilep- 
tics of  long  standing  develop  a  persistent  atony 
of  the  stomach.  This  fact  was  readily  demon- 
strable in  all  epileptics  whose  stomach  he  had 
occasion  to  examine. 

Another  curve  obtained  in  connection  with 
the  case  of  a  female  patient  who  suffers  from 
[140] 


A   NEW  METHOD   OF  TREATMENT 

nocturnal  frights  is  submitted.  The  more  fre- 
quently these  gastric  phenomena  in  migraine 
and  epilepsy  are  observed,  the  more  diagnostic 
value  do  they  seem  to  possess  in  judging  of 
these  two  diseases,  always  believed  to  stand  in 
close  relation  to  each  other. 

Thus  the  accompanying  curve  demonstrates 
conclusively  the  close  connection  between  the 
nocturnal  fright  of  adults  and  epilepsy.  In  an- 
other case  of  nocturnal  fright  in  a  gentleman 
thirty-one  years  of  age,  the  same  curve  was  ob- 
tainable. 

Dr.  Mangelsdorf  purposely  refrains  from  all 
reference  to  the  literature  on  this  subject,  as 
well  as  any  attempt  to  explain  these  phenom- 
ena, or  from  dwelling  upon  the  details  and  very 
interesting  histories  of  cases,  and  rather  refers 
to  the  very  satisfactory  and  encouraging  results 
obtained  for  migraine  patients,  by  relieving  the 
stomach  atony- — patients  whom  he  was  able  to 
observe  for  several  successive  years. 

Abdominal  strapping,  according  to  my  expe- 
rience, seems  in  a  few  cases  to  be  prescriptible, 
as  an  adjuvant  at  least,  in  acne  rosacea. 
[141] 


ATONIA   GASTRICA 


I  was  called  in  consultation  to  a  case  of 
atonia  gastrica  associated  with  hyperchlorhydria 
and  serious  gastric  disturbances.  Another  af- 
fection, which,  however,  I  did  not  consider  at 
first  in  suggesting  treatment,  was  well-marked 
acne  and  rosacea.  I  confined  myself  to  apply- 
ing the  plaster  strapping,  and  recommending 
Illoway's  diet  for  hyperchlorhydria. 

The  patient  was  extremely  lean,  one  of  those 
cases  in  which  no  kind  of  bandage,  or  abdomi- 
nal supporter  made  by  the  bandager,  will  Tit  and 
give  support  to  the  relaxed  abdominal  walls  and 
organs. 

I  saw  the  lady  again  some  weeks  after  the 
first  consultation.  A  marked  improvement  in 
every  direction  was  noticed;  not  only  had  the 
gastric  symptoms,  of  which  she  had  complained, 
been  relieved,  but  acne  and  rosacea  were  decid- 
edly less  noticeable. 

It  is  a  well-established  fact  that  gastric  and 
intestinal  disorders  bear  relation  to  the  appear- 
ance of  acne,  but  the  apparently  close  relation 
between  atonia  gastrica  and  acne,  as  manifested 
in  this  case,  had  never  before  suggested  itself 
to  my  mind.  Here  it  was  a  mere  accidental 
observation,  for  I  had  not  been  prepared  to  see 
[142] 


A   NEW   METHOD   OF  TREATMENT 

the  skin  disorder  relieved  so  promptly  by  means 
of  strapping  the  abdomen. 

Not  long  after  this  first  observation  had  been 
made,  a  young  lady  teacher  came  to  my  office  to 
be  treated  for  acne,  this  most  common  of  all 
skin  disorders.  Her  face  was  seriously  disfig- 
ured, causing  her  much  embarrassment.  For 
two  years  she  had  been  treated ;  she  had  con- 
sulted specialists,  and  an  endless  number  of 
remedies,  advised  by  physicians  and  by  friends ; 
strict  dieting — the  worst  of  all — had  been  tried 
in  vain. 

This  patient,  likewise,  had  atonia  gastrica; 
the  splashing  sound  could  be  easily  elicited  over 
a  large  area ;  her  appetite  was  excellent,  gastric 
symptoms  she  had  none,  but  she  was  very  thin. 
On  account  of  this  habit,  while  the  appetite  was 
good,  the  digestion  likewise  all  that  could  be 
desired,  I  judged  (without  tormenting  the  patient 
with  the  stomach  tube)  that  there  must  be  an 
unnecessarily  large  amount  of  free  hydrochloric 
acid  in  her  stomach,  and  I  ordered  her  to  drink 
as  much  olive  oil  as  she  could — at  least  three 
tablespoonfuls  a  day — in  order  to  reduce  the  su- 
perfluous amount  of  acid  in  the  stomach,  and 
for  another  reason  of  which  I  shall  speak  pres- 
[143] 


ATONIA   GASTRICA 


ently.  It  is  well  known  that  the  ingestion  of 
olive  oil  reduces  the  amount  of  hydrochloric 
acid  in  the  stomach. 

I  applied  the  abdominal  plaster  belt,  and, 
without  going  into  details,  I  wish  to  state  that 
the  acne  was  promptly  cured  in  the  course  of 
time.  It  is  true  it  would  appear  again  for  a  few 
days  about  the  time  of  menstruation,  but  in  a 
milder  form,  not  to  be  compared  with  the  af- 
fliction before  the  abdominal  strapping  was 
applied. 

The  following  cases  have  been  reported  by 
Dr.  R.  Weissmann: 

Mrs.  B.  L ,  hysteroneurasthenia,  habit- 
ual obstipation,  insomnia,  inability  to  walk  any 
considerable  distance.  Pendent  abdomen,  right- 
sided  floating  kidney.  Bandage  applied.  Pa- 
tient at  once  enabled  to  walk  longer  distances. 
Digestion  is  improved,  the  nervous  manifesta- 
tions subside. 

Miss  M.  S complains  of  dizziness,  head- 
ache, tired  feeling,  habitus  enteroptoticus  of 
Stiller,  splashing  sounds  as  much  as  six  to  seven 
hours  after  meals.  Bandage  applied.  Imme- 
diate improvement  of  symptoms.  The  patient 
[144] 


A   NEW   METHOD   OF  TREATMENT 

leaves  for  home  after  three  days,  but  after  a  few 
weeks  pens  request  for  a  new  bandage  which 
has  done  excellent  service. 

Mrs.  G.   S ,  64  years  old.      Obstipation, 

loss  of  appetite,  feeling  of  downward  pressure, 
heartburn,  eructations,  impeded  movements  on 
account  of  abdominal  sensitiveness,  emaciation, 
occasional  headache  and  fever,  pendent  belly, 
splashing  sound.  Bandage  applied.  Improve- 
ment of  general  condition  in  a  few  days.  The 
support  is  worn  for  six  weeks,  and  agrees  cap- 
itally. After  three  months  the  patient  asks 
my  presence  at  a  considerable  distance  for 
the  adjusting  of  a  new  bandage,  conclusive 
evidence  of  the  beneficial  effect  of  the  first 
bandage. 

Miss  A.  H ,  hystero-epileptic  convulsions, 

melancholy  moods,  persistent  obstipation,  con- 
siderable eructations,  heart  palpitation,  habitus 
enteroptoticus,  splashing  sound,  right-sided 
floating  kidney.  Bandage  applied.  Disposition 
more  serene,  hysterical  attacks  diminish,  move- 
ments of  bowels  become  regular. 

Miss  V.  A ,  for  two  years  almost  unin- 
terrupted headache,  insomnia,  obstipation,  hab- 
itus enteroptoticus,  right  floating  kidney.  After 
application  of  first  bandage,  immediate  sound 
10  [145] 


ATONIA   GASTRICA 


sleep,  amelioration  of  headaches.  After  four 
bandagings  notable  improvement;  patient  not 
heard  from  since. 

The  following  case  from  my  own  practise  is 
of  special  interest,  confirming  what  a  German 
observer  has  said,  namely,  that  the  adhesive 
plaster  dressing  will  in  many  instances  prove 
of  better  service  than  all  the  pessaries : 

Miss  V ,   25  years    old,  American,    had 

studied  at  European  universities;  now  teach- 
ing at  college.  Came  to  my  office  July  20, 
1904.  Dysmenorrhea.  Menstruated  since  her 
fifteenth  year;  never  without  dysmenorrhea. 
As  a  rule,  pain  was  so  excessive  as  to  confine 
her  to  bed  for  two  days  during  the  monthly 
period.  Treatment,  curetting  included,  had 
been  of  no  avail.  Uterine  flexion,  descensus, 
and  enlargement  of  both  ovaries.  Well-pro- 
nounced splashing  sound.  Except  frequent  at- 
tacks of  nausea,  no  gastric  symptoms,  not  even 
constipation.     Plaster  applied. 

July  29.  After  menstruation.  At  this  period 
there  had  been  much  less  difficulty  than  ever  be- 
fore. Was  confined  to  bed  for  a  few  hours  only. 
Bandage  is  well  borne. 

[146] 


A   NEW   METHOD   OF   TREATMENT 

September  lo.  Last  menstruation  had  been 
still  less  troublesome  than  preceding  one. 
Bandage  had  become  loose  and  was  removed. 
There  is  no  splashing  sound,  not  even  after 
drinking  water.  From  this  time  on,  notwith- 
standing that  no  bandage  was  applied  anew, 
patient  passed  her  menstrual  period  without  any 
pain. 

The  beneficial  effect  in  such  cases,  I  think, 
was  due  to  the  equally  distributed  pressure  on 
the  abdominal  walls,  which  pressure,  no  doubt, 
influenced  circulation  and  innervation.  The 
plaster-of- Paris  dressing  applied  in  case  of  frac- 
ture acts  in  an  analogous  manner.  It  is  certain 
that  we  can  not  secure  equally  distributed  pres- 
sure by  means  of  abdominal  supporters,  made 
by  bandagers,  to  such  perfection  as  we  can  by 
means  of  the  plaster  bandage.  The  same  dif- 
ference may  be  noted  in  the  effects  produced  by 
splints  and  those  by  plaster  of  Paris,  in  the 
treatment  of  fractures. 

German  writers  have  pointed  out  that  the 
plaster  bandage  is  the  ideal  prophylactic  post 
partum,  especially  against  hemorrhage  and 
[147] 


ATONIA  GASTRICA 


ptosis.  I  can  confirm  this,  in  so  far  as  the  mul- 
tiparae  on  whom  I  had  applied  the  plaster  after 
confinement  were  enthusiastic  in  praising  it 
when  compared  with  the  binder  they  had  had 
after  former  partus. 

There  exists  a  peculiar  form  of  gastritis — if 
we  may  classify  it  as  gastritis — a  form  which 
has  been  described  much  in  recent  literature. 
It  is  gastritis  caused  by  development  of  mold  in 
the  stomach.  A  case  of  this  kind  came  to  the 
Post-Graduate  Clinic  in  April,  1902. 

Mrs.  M.  J ,  56   years   of  age.     She  had 

been  suffering  all  winter  from  loss  of  appetite, 
nausea,  vomiting,  and  irritation  of  the  throat; 
the  main  complaints  were  of  a  burning  sensation 
in  the  throat  and  vomiting  of  almost  everything 
she  ate.  There  was  a  great  deal  of  gas  in  the 
stomach,  but  the  pain  was  confined  to  the 
esophagus.  She  was  very  anemic,  and  had  lost 
during  her  sickness  twelve  pounds  in  weight. 
There  was  a  tumor  felt  in  the  epigastrium, 
somewhat  toward  the  left  side;  well  pro- 
nounced splashing  sound,  nephroptosia.  Blood 
examination  was  made  by  a  colleague,  but  I 
have  lost  the  record.  However,  it  is  imma- 
[148] 


A   NEW  METHOD   OF  TREATMENT 

terial.  After  the  patient  had  been  given  condu- 
rango,  methylene  blue,  and,  in  order  to  give 
temporary  relief,  small  doses  of  morphin,  all  in 
vain,  I  resorted  to  plaster  strapping  and  ordered 
creosote  in  three-drop  doses.  The  strapping  at 
once  gave  great  relief;  the  patient  spoke  with 
enthusiasm  of  the  comfort  experienced.  She 
recovered  rapidly  and  gained  in  weight.  The 
tumor  as  well  as  the  splashing  sound  had  van- 
ished by  the  time  the  plaster  had  been  on  five 
weeks. 


This  was  a  case  of  mold  in  the  stomach. 

By  what  other  means,  I  wish  to  ask,  could 
this  patient  have  been  relieved  so  promptly.' 
The  creosote,  it  is  true,  may  have  destroyed  the 
mold,  altho  it  is  doubtful  if  three-drop  doses 
were  sufficient  to  accomplish  this;  but  the  stag- 
nation, the  motor  insufficiency,  could  be  im- 
proved only  by  mechanical  measures.  No  ban- 
dager  could  have  made  for  this  emaciated  pa- 
tient an  abdominal  supporter  which  would 
have  adapted  itself  and  exerted  equally  divided 
pressure  and  support  as  the  plaster  strapping 
did. 

[149] 


ATONIA   GASTRICA 


The  following  two  cases  confirm  what  a 
German  writer  has  said  on  the  good  services  of 
the  adhesive-plaster  bandage  in  some  chronic 
cases : 

The  first  was  that  of  a  young  man  whom  I 
brought  for  demonstration  before  the  Clinical 
Society  of  the  New  York  Post- Graduate.  He 
had  been  suffering  from  severe  gastric  symptoms 
for  fifteen  years ;  was  emaciated,  had  not  had, 
according  to  his  expression,  a  good  day  free  from 
distress  during  all  these  fifteen  years.  He  had 
strongly  pronounced  gastroptosia  and  hyper- 
chlorhydria.  Neither  the  medical  treatment  of 
hyperchlorhydria  nor  the  application  of  an  ab- 
dominal supporter,  ordered  by  a  colleague  and 
made  by  a  bandager,  gave  relief.  I  applied  the 
plaster,  and  from  the  very  day  the  plaster  was 
applied  he  began  to  improve,  gained  four  pounds 
in  weight  during  the  first  week,  and  when  I 
presented  him  before  this  society,  four  weeks 
after  the  strapping,  he  had  gained  eleven  pounds 
and  was  free  from  all  gastric  symptoms.  He 
presented  himself  from  time  to  time  after- 
ward and  is  now  in  a  perfectly  healthy  condi- 
tion. 

Another  case  was  that  of  one  of  the  matricu- 
[ISO] 


A   NEW   METHOD    OF   TREATMENT 

lates  of  the  Post-Graduate,  who  had  been  a  suf- 
ferer for  twelve  years  from  gastric  symptoms ; 
he  had  hyperchlorhydria  and  well-pronounced 
enteroptosia.  Strapping  gave  relief  at  once 
and  permanently.  This  case  has  been  published 
by  the  patient  himself  in  The  Post-Graduate. 
He  had  worn  the  plaster  I  applied  for  seventy- 
five  days. 

Whatever  has  been  said  to  the  contrary,  the 
positive  fact  is  that  the  strapping  is  very  well 
tolerated  by  most  patients,  and  the  contrivances 
of  the  bandagers  are  absolutely  useless  in  the 
case  of  lean  persons. 


[151] 


IV 

FLOATING   KIDNEY 

At  the  seventy-fifth  annual  meeting  of 
German  Naturalists  and  Physicians,  September 
22,  1903,  Dr.  B,  Schmitz,  of  Bad  Wildungen, 
spoke  on  movable  kidney  and  demonstrated  a 
new  method  of  treatment,  namely,  adhesive- 
plaster  strapping,  which  he  had  conceived  inde- 
pendently of  us  (Rose water  and  myself),  and  had 
for  some  time  employed  exclusively  in  such 
cases.     His  remarks  were  as  follows  : 

Ren  mobilis,  in  its  severest  forms  familiarly 
styled  floating  kidney,  is  not  of  rare  occurrence, 
and  its  treatment  is  frequently  demanded.  Al- 
tho  it  is  impossible  to  give  exact  statistics  as  to 
the  prevalence  of  this  disorder  in  the  living,  we 
may  assume  that  it  happens  in  from  12  to  15 
per  cent,  of  the  population.  In  100  necropsies 
in  which  the  positions  and  relations  of  the  kid- 
neys were  especially  noted,  Wolkow  and  De- 
[152] 


FLOATING  KIDNEY 


litzin  found  1 5  movable  kidneys.  Another  ob- 
server found  it  only  in  12  per  cent. 

It  is  a  fact  that  women  are  more  apt  to  suffer 
from  this  disorder  than  men.  Of  the  two  kid- 
neys, the  right  one  is  more  often  displaced  than 
the  left.  Most  frequently  is  movable  kidney 
found  in  that  period  of  life  extending  from  the 
twentieth  to  the  thirtieth  year.  No  age,  how- 
ever, is  exempted  excepting  earliest  childhood. 

The  kidneys  are  located  in  the  abdominal 
cavity  along  the  lumbar  vertebral  column  in  the 
prevertebral  niche  in  the  excavation  of  the  dia- 
phragm, and  there  they  are  fastened  in  the  first 
place  by  the  capsule  by  which  they  are  enclosed, 
and  next  anteriorly  by  an  abdominal  adipose 
fold;  further  by  the  truncus  of  vessels  and 
nerves,  and  are  finally  secured  in  place  by  the 
abdominal  pressure  of  the  intestine. 

The  kidneys  are  not  absolutely  immovable. 
They  participate  to  a  certain  extent  in  the 
respiratory  excursions  of  the  diaphragm,  but 
under  normal  conditions  to  such  a  degree  only 
that  they  are  not  palpable. 

As  soon  as  we  can  palpate  a  part  of  the  kid- 
[153] 


ATONIA   GASTRICA 


ney  (for  instance,  the  lower  pole),  or  more  so, 
two-thirds  of  the  organ,  and  are  able  by  means 
of  a  certain  grasp  and  pressure  to  displace  the 
whole  organ,  we  speak  of  an  abnormally  mov- 
able kidney. 

In  some  instances,  even  when  the  kidney  is 
very  movable,  there  may  be  no  symptoms  indi- 
cating a  pathological  position  of  the  kidney,  and 
the  anomaly  is  discovered  only  by  accident. 

If  the  severity  of  the  therapeutic  measures 
corresponded  with  the  difficulty  of  treatment, 
then  the  surgical  operations  which  have  been 
suggested  and  practised  for  relief  from  floating 
kidney  would  give  us  an  idea  what  difficulties 
a  floating  kidney  offers. 

We  will  not  investigate  the  conditions  under 
which  radical  surgical  measures  are  prescribed, 
but  we  will  emphasize  the  fact  that  in  the  first 
place  milder,  unbloody  methods  should  be 
considered,  the  more  so  since  the  surgical  oper- 
ations, under  the  most  favorable  circumstances, 
have  not  given  the  good  results  expected  from 
them. 

The  mild,  unbloody  methods  aim  to  secure 
[154] 


FLOATING  KIDNEY 


the  movable  kidney  in  its  place  by  means  of 
bandages.  Some  have  combined  the  dressing 
with  a  pelote  fastened  below  the  costal  arch  so 
as  to  press  directly  upon  the  kidney  and  thereby 
to  keep  it  in  place. 

I  do  not  approve  of  this  pelote  treatment, 
because  a  permanent  pressure  on  a  kidney  can 
never  be  beneficial ;  moreover,  this  application 
may  be  dangerous  when  the  kidney,  as  may 
easily  happen,  changes  its  place  and  is  thus 
forced  by  pressure  to  retain  the  malposition. 

Dr.  Schmitz  then  describes  the  methods 
most  generally  employed  and  well  known,  and 
speaks  of  their  disadvantages.  His  own  (the 
application  of  an  adhesive-plaster  dressing)  has 
been  described  by  Rosewater  as  follows  :  Under 
moderate  traction  a  strip  of  adhesive  plaster  5 
cm.  wide  is  applied  horizontally  from  the  left  to 
the  right  side  on  the  abdomen,  directly  over  the 
symphysis;  this  strip  is  extended  on  the  af- 
fected side  parallel  with  the  crest  of  the  ilium 
to  the  back,  crossing  the  back  in  an  oblique 
direction  until  it  overlaps  the  spine. 

He  suggests  fixation  of  the  kidney  by  means 
[155] 


ATONIA   GASTRICA 


of  plaster  strapping,  as  already  mentioned  in  a 
former  chapter,  in  every  case  of  chronic  nephri- 
tis, and  reasons  as  follows :  The  diseased,  in- 
flamed, and  irritated  kidney  will  suffer  intensely 
from  vibrating  and  thrusting  shocks.  Riding 
in  railroad  cars  or  carriages  is  always  injurious  to 
patients  with  kidney  disease.  Even  the  shaking 
which  every  step  in  walking  transmits  to  the 
kidney  is  unpleasantly  felt  by  nephritic  patients. 
He  has  observed  that  patients  with  kidney  dis- 
ease felt  more  comfortable  as  soon  as  the  kid- 
neys had  been  secured  by  plaster  strapping,  and 
that  the  amount  of  albumin  in  the  urine  was 
lessened  during  treatment  by  strapping. 

Dr.  Schmitz,  in  treating  movable  kidney,  has 
overlooked  the  fact  that  movable  kidney  means 
gastroptosia,  and  that  he  did  not  treat  symp- 
toms originating  in  particular  from  the  kidney 
but  those  which  were  in  most  instances  mani- 
festations of  gastroptosia. 

I  hope  he  will  pardon  me  if  I  give  in  the 

following  emphatic  way  my  own  views  on  this 

subject.     These  remarks  formed  the  contents  of 

a  paper  which  I  had  written  in  February,  1902, 

[156] 


FLOATING   KIDNEY 


published  under  the  title  "  Floating  Kidney 
Idolatry,"  and  aimed  at  the  overzealous  sur- 
geons who  went  so  far  as  to  recommend  nephro- 
pexy in  about  every  case  of  movable  kidney. 

At  hazard — it  happened  to  be  the  first  of 
some  papers  on  the  subject  which  fell  into  my 
hands  one  day — I  read  an  article  by  Alexander 
Macgregor  in  The  Lancet  of  December  14,  1901, 
entitled,  "  Movable  or  Floating  Kidney  a  Cause 
of  Acute  and  Chronic  Painful  Dyspepsia,"  etc. 

The  author  says  :  "  The  cause  of  dyspepsia  in 
some  cases  is  not  the  stomach  itself,  but  the 
symptoms  are  due  to  the  wanderings  of  a  float- 
ing kidney.  Except  in  those  cases  where  the 
dislocation  interferes  with  the  function  of  the 
kidney  itself  no  symptom  points  directly  to  the 
nephroptosia.  The  kidney  is  not  really  thought 
of  as  being  the  cause  of  an  acute  attack  of 
jaundice  with  sickness  and  severe  pain  in  the 
epigastrium,  yet  it  has  been  known  to  give  rise 
to  such  symptoms." 

Schleiden  has  shown  that  some  natural  phi- 
losophers have  accused  the  moon  of  influences  on 
events  in  nature  of  which  she  is  innocent,  and 
[157] 


ATONIA   GASTRICA 


compares  the  role  the  moon  is  made  to  play  with 
the  role  of  the  cat  accused  of  having  broken 
dishes  while  the  kitchen  maid  is  the  malefac- 
tress.  This  applies  to  the  role  the  floating  kid- 
ney is  made  to  play  in  regard  to  gastric  and 
nervous  symptoms. 

Studying  the  history  of  medicine  or  the  his- 
tory of  religion,  we  see  that  nothing  is  too  para- 
doxical to  find  believers,  at  least  for  a  time. 
The  importance  which  at  present  is  attributed 
to  a  floating  kidney  is  one  of  these  aberrations 
of  men  of  science  of  which  we  find  examples 
enough  in  history.  It  is  surprising  to  observe 
how  much  learning  has  sometimes  been  em- 
ployed by  serious  men  to  support  a  theory  which 
appears  in  a  later  period  entirely  unscientific. 
Such  errors  are  the  more  dangerous  the  higher 
the  authority  which  pronounces  them,  and  the 
more  generally  the  errors  are  prevailing. 

Macgregor  describes  a  number  of  cases  in 
which  one  or  both  kidneys  were  movable,  in 
which  the  abdominal  walls  were  flaccid,  making 
palpation  easy ;  the  kidneys  were  easily  grasped 
and  could  be  moved  over  a  wide  area,  and  in  all 
[158] 


FLOATING  KIDNEY 


these  cases,  as  he  remarks,  nothing  abnormal 
was  detected  in  the  stomach.  These  italicized 
words  are  all  he  says  about  the  stomach.  We 
do  not  learn  if  the  motoric  functions  of  this 
organ  were  intact ;  he  does  not  mention  how  and 
for  what  he  has  examined.  Some  think  they 
have  done  enough  when  they  have  introduced 
the  tube,  examined  the  secretory  functions  and 
the  chemistry  of  the  stomach;  our  English  col- 
league does  not  say  whether  he  has  even  done 
that  much.  He  does  not  tell  us  anything  of 
the  position  of  the  stomach.  But  we  will  not 
address  this  reproach  to  this  author  alone. 
There  exists  a  large  fraternity,  there  is  a  volu- 
minous literature  of  recent  date  giving  us  a 
litany  of  symptoms  and  depicting  in  vivid 
colors  all  the  mischief  attributed  to  floating 
kidney.  A  new  specialty  has  developed,  which 
we  may  name  nephroptosiology. 

Macgregor's  treatment  in  all  his  cases  was  to 
apply  an  abdominal  bandage,  and  in  no  instance 
has  he  found  it  necessary  to  recommend  opera- 
tion. In  selecting  this  mode  of  treatment  he 
fulfilled  the  first  indication  which  presents 
[159] 


ATONIA   GASTRICA 


itself  in  cases  of  gastroptosia  whether  the  stom- 
ach alone,  the  liver  alone,  or  the  kidney  alone, 
or  all  the  splanchnon  is  concerned,  for  the  ra- 
tional proceeding,  as  we  shall  see,  is  to  give 
relief  to  the  patient  by  supporting  the  abdom- 
inal walls,  and  in  the  great  majority  of  cases 
this  is  indeed  all  that  is  required. 

It  is  an  established  fact  that  patients  with 
gastroptosia  have,  as  a  rule — but  by  no  means 
in  all  cases — dyspeptic  or  nervous,  or  dyspeptic 
and  nervous  symptoms.  My  observations  have 
demonstrated,  nay,  have  furnished  conclusive 
evidence,  that  these  nervous  and  dyspeptic 
symptoms  may  be  connected  directly  with  the 
displacements  of  the  abdominal  organs. 

Patients  with  gastroptosia,  with  or  without 

nephroptosia,  with  nephroptosia  of  the  first,  the 

second,  the  third,  or  fourth  degree,  received  the 

treatment  I  have  described  repeatedly — that  is, 

the  abdomen  was  strapped  with  rubber  plaster 

and  in  numerous  cases  and  in  a  very  short  time 

the   gastric   and   nervous    symptoms    subsided. 

Relief  of  the  gastroptosia  secured  relief  of  the 

gastric  and  nervous  symptoms. 
[i6o] 


FLOATING  KIDNEY 


V.  Krafft-Ebing  sounds  a  warning  not  to  as- 
sume too  quickly  that  gastric  symptoms  are  the 
cause  of  neurasthenia  in  cases  of  neurasthenia 
associated  with  gastric  symptoms,  but  when 
treatment  of  gastroptosia  is  followed  by  cessa- 
tion of  neurasthenic  symptoms  there  can  be  no 
doubt  of  the  relation  of  the  one  to  the  other. 

The  same  author  warns  also  against  overesti- 
mation  of  the  importance  of  the  floating  kidney 
so  often  found  in  emaciated  neurasthenic  plurip- 
arae.  He  says  that  in  many  instances  this  float- 
ing kidney  becomes  of  importance  only  when  the 
attention  of  patients  has  been  directed  to  it,  and 
when  their  minds  become  occupied  with  this 
wandering  organ.  V.  Krafft-Ebing  has  adopted 
the  principle  not  to  reveal  to  the  patient  the 
interesting  discovery  of  a  floating  kidney,  and 
to  make  little  of  it  in  case  the  patient  has  been 
informed  by  some  other  physician,  or  to  take 
advantage  of  the  patient's  knowledge  of  the 
presence  of  a  floating  kidney  by  telling  them 
that  they  have  to  eat  well  to  reduce  the  ptosis. 
Besides,  he  considers  this  the  best  remedy 
against  the  wandering  of  the  abdominal  organs. 
II  [i6i] 


ATONIA  GASTRICA 


Quite  so,  we  will  agree  with  v.  Krafft-Ebing, 
but  in  order  to  have  patients  eat  well  and  gain 
in  weight  we  have  to  strap  the  abdomen.  This 
is  what  I  have  found  to  be  the  best  means  to 
restore  the  gastric  functions,  and  thereby  the 
best  remedy  against  the  wandering  of  the  ab- 
dominal organs. 

Before  I  was  aware  of  v.  Krafft-Ebing's  prin- 
ciple not  to  speak  to  the  patient  about  the  float- 
ing kidney  I  had  adopted  it  myself,  because 
such  a  course  suggested  itself  some  years  ago 
in  New  York  while  the  floating  kidney,  thanks 
to  some  enthusiastic  surgeons,  was  in  fashion. 

It  is  self-evident  that  there  are  cases  of 
gastroptosia  in  which  disorders  or  disturbances 
are  directly  due  to  displacement  of  the  kidney, 
and  that  surgical  interference  in  such  instances 
may  be  required,  but  I  shall  not  dwell  on  these 
exceptions.  In  most  instances  all  symptoms 
due  to  gastroptosia,  but  which  may  have  been 
ascribed  erroneously  to  the  kidney  alone,  will 
be  relieved  by  the  most  rational,  by  the  simplest 
method  imaginable,  the  restitution  of  the  tone 
of  the  abdominal  muscles,  and  this  relief  is  very 
[162] 


FLOATING  KIDNEY 


often  a  permanent  one,  as  I  have  had  occasion 
to  observe.  Not  only  do  the  gastric  and  the 
nervous  symptoms  disappear  within  a  short 
time  and  the  patients  gain  flesh,  but  the  im- 
provement is  lasting.  Some  patients  who  had 
been  suffering  for  many  years  before  treatment, 
and  whom  I  saw  again  one  and  two  years  after 
treatment,  had  no  splashing  sound  any  more, 
no  more  displacement  of  kidney,  and  enjoyed 
perfect  health  in  general. 

There  are  cases  in  which  the  gastroptosia  is 
due  to  neurasthenia  and  in  which,  notwithstand- 
ing the  treatment  by  means  of  strapping,  the 
splanchnoptosia  will  persist  so  long  as  the  pri- 
mary cause  is  not  removed,  but  even  in  these 
instances  great  benefit  is  derived  from  the  sup- 
port of  the  abdominal  muscles.  I  have  had 
such  a  case  under  observation  for  two  years; 
the  patient  is  a  poor  woman,  very  much  emaci- 
ated, with  well-pronounced  splanchnoptosia  and 
complete  and  permanent  achylia.  The  ab- 
dominal strapping  has  helped  considerably  to 
ameliorate  her  nervous  condition,  to  enable  her 
to  do  work;  she  is  enthusiastic  in  praising  the 
[163] 


ATONIA   GASTRICA 


beneficial  effect  of  the  strapping,  and  has  it 
renewed  about  every  two  months.  She  has 
gastric  trouble  only  when  she  deviates  from  the 
prescribed  diet,  but  the  splanchnoptosia  and  the 
emaciation  remain  the  same  as  they  were.  I 
doubt  very  much  whether  in  this  case  anchoring 
of  the  displaced  kidney  would  be  of  any  service 
whatever.  I  should  feel  inclined  to  say  as  the 
Frenchmen  express  themselves  about  certain 
remedies  :  "  If  it  does  no  harm,  it  can  do  no 
good." 

My  experience  tells  me  that  we  are  not  justi- 
fied in  resorting  to  operation,  in  performing 
nephropexia,  without  having  first  tried  the 
method  of  supporting  the  abdominal  muscles, 
and  that  the  method  of  strapping  seems  to  me 
the  best  of  all  the  methods  to  this  end. 

James  Israel,  of  Berlin,  at  the  International 
Congress  in  Moscow  in  the  year  1897,  said: 
"  Careful  observation  made  on  a  great  number 
of  cases  has  convinced  me  that  the  operation  of 
nephropexy  is  very  often  superfluous  and  irra- 
tional, because  the  many  symptoms  which  are 
attributed  to  movable  kidney — a  very  common 
[164] 


FLOATING  KIDNEY 


occurrence — are  in  only  a  very  small  number  of 
cases  really  related  to  this  displacement ;  these 
symptoms  are  caused  mostly  by  general  enterop- 
tosia  or  neurasthenia  or  affections  of  the  gen- 
erative system."  He  speaks  against  the  popu- 
larization of  this  affection,  because  many  women 
who  have  heard  of  floating  kidney  and  all  the 
ghost  stories  about  them,  keep  these  horrors  in 
their  minds  and  have  no  peace  until  they  are 
operated  on. 

L.  Bazet,  in  the  Transactions  of  the  Medical 
Society  of  the  State  of  CaHfornia,  1898,  gives 
a  resume  of  the  condition  and  advances  of  renal 
surgery  up  to  that  date.  He  says  :  "  There  are 
patients — they  are  mostly  women — in  whom 
the  floating  kidney  is  but  a  part  of  a  complex 
condition,  where  enteroptosia  and  neurasthenia 
appear  to  play  the  principal  role.  Here  all  the 
viscera  are  altered  in  their  suspension,  and 
these  patients  are  nervous  in  the  proper  mean- 
ing of  the  word.  When  in  such  cases  nephro- 
pexy is  performed  there  is  absolutely  no  thera- 
peutic benefit." 

Nephropexy  in  cases  of  floating  kidney  was 
[165] 


ATONIA   GASTRICA 


one  of  the  first  methods  employed  in  renal  sur- 
gery. As  always  happens  when  a  new  operation 
springs  up  with  the  relative  security  of  modern 
asepsia,  the  number  of  operators  is  increased, 
thoughtlessness  creeps  in,  and  the  proper  in- 
dications are  not  sufficiently  studied  to  justify 
the  reasonable  propriety  for  surgical  interfer- 
ence. Such  was  and  is  yet  the  case  with 
nephropexy.  Bazet,  in  the  paper  quoted  al- 
ready, says  failures,  observations,  and  expe- 
rience, all  carefully  reported,  threw  a  new  light 
on  the  subject,  and  now  such  an  authority  as 
Israel  has  come  to  the  determination  systemati- 
cally to  refuse  operation  in  nephroptosia. 

In  order  to  show  once  more  how  necessary  it 
is  to  clear  up  the  existing  confusion  in  regard 
to  medical  terms,  let  us  quote  at  hazard  from  a 
paper  in  The  Journal  of  the  A  nierican  Medical 
Association  lox  October  6,  1900:  "Nephropexy 
will  often  fail  in  wandering  kidney  brought 
about  by  gastroptosi^  and  enteroptosis. "  The 
same  paper  treats  of  a  case  in  which  the  right 
kidney  descended  so  far  as  to  touch  the  bladder, 
and  was  easily  palpated  in  any  position,  but,  as 
[166] 


FLOATING   KIDNEY 


the  author  adds,  there  was  no  enteroptosis.    This 
is  a  regular  contradictio  in  adjectu. 

The  floating  kidney  idolatry  is  a  thing  of  the 
past,  therefore  this  chapter  can  be  regarded 
merely  as  a  contribution  to  medical  history. 


[167] 


V 

TYPE   OF    ADHESIVE   PLASTER    FOR 
THE   ABDOMINAL    BELT 

By  R.   C.   KEMP 

One  of  the  most  important  features  in  the 
treatment  by  means  of  the  adhesive-plaster 
belt  is  the  employment  of  the  proper  type  of 
plaster.  Irritation  of  the  skin  of  a  most  dis- 
agreeable kind  results  from  the  use  of  improper 
material.  The  stiffer  varieties  of  plaster  do  not 
exercise  equable  pressure ;  they  kink  into  folds, 
eroding  the  skin,  do  not  adhere  closely  in  every 
part,  and  hence  allow  accumulation  of  sweat 
beneath  the  plaster  with  resulting  irritation. 

In  the  first  instance  no  other  but  rubber  ad- 
hesive plaster  can  be  employed. 

The  adhesive    plaster   of    the   pharmacopeia 
contains  fourteen  per  cent,  of  finely  powdered 
resin,  eighty  per  cent,  of  lead  or  diachylon  plas- 
ter, and  six  per  cent,  of  yellow  wax. 
[168] 


PLASTER   FOR  ABDOMINAL   BELT 

The  action,  however,  is  not  always  satisfac- 
tory, because  it  often  happens  that  delicate 
skins  are  irritated  by  this  large  proportion  of 
resin,  and  eruptions  are  produced  that  interfere 
with  the  retention  of  the  dressing.  Moreover, 
the  resin  plaster  is  not  adhesive  at  the  tempera- 
ture of  the  human  body,  and  must  be  heated  in 
order  to  adhere  properly.  It  may  also  be  made 
more  sticky  by  slightly  brushing  the  surface 
with  a  little  chloroform,  which  dissolves  some 
of  the  resin.  The  latter  expedient,  altho  more 
convenient  than  that  of  heating,  has  been  found 
to  increase  the  tendency  to  irritation  of  the 
skin,  already  referred  to. 

Rubber  adhesive  plaster  is  free  from  the  ob- 
jections to  resin  plaster,  and  is  ready  for  appli- 
cation without  any  preparation.  These  advan- 
tages have  led  surgeons  of  the  present  day  to 
discard  almost  entirely  the  official  plaster  from 
their  armamentarium,  and  now  when  an  opera- 
tor asks  for  a  piece  of  adhesive  plaster,  the 
assistant  invariably  gives  him  the  rubber  adhe- 
sive without  a  thought  that  there  may  be  an- 
other kind.  In  fact  it  is  seldom  a  modern  sur- 
[169] 


ATONIA   GASTRICA 


geon  employs  resin  or  soap  plaster  for  the 
dressing  of  wounds,  or  for  making  an  extension 
after  a  fracture. 

In  the  summer  of  1900,  while  at  Athens,  Dr. 
Rose  endeavored  to  demonstrate  his  belt,  but 
was  unable  to  do  so  because  rubber  plaster  was 
not  known  and  could  not  be  procured  in  Greece. 

He  met  with  another  curious  experience 
when  he  attempted  to  compare  the  German 
plasters  spoken  of  in  the  writings  of  Clemm, 
Weissmann,  and  Schmitz  with  our  American 
plasters.  He  was  unable  to  obtain  a  sample, 
and  a  piece  which  had  been  imported  at  his 
expense  disappeared  before  he  had  tried  it. 
Hence  we  were  unable  to  compare  the  German 
with  the  American  adhesive  plaster.  We  only 
know  from  the  writers  quoted  that  oxide  of 
zinc  rubber  plaster  on  moleskin  is  now  exclu- 
sively used  in  Germany  for  abdominal  strapping. 

Moleskin  plaster  has  been  employed  by  the 
surgeons  for  a  great  period  of  time.  I  myself 
noted  especially  in  one  case  of  fracture  of  the 
neck  of  the  humerus,  in  a  patient  whose  skin 
was  exceptionally  sensitive,  that  the  rubber  ad- 
[170] 


PLASTER   FOR  ABDOMINAL  BELT 

hesive  plaster  on  moleskin  caused  less  irrita- 
tion even  than  the  zinc  oxide  spread  on  muslin. 
This  seemed  strange  at  first,  but  it  was  noted 
on  investigation  that  the  moleskin  adapts  itself 
much  more  closely  to  the  parts  than  does  the 
plaster  with  ordinary  backing. 

The  moleskin  plaster  for  Rose's  belt  was,  I 
can  fairly  claim,  first  applied  in  this  country 
at  my  clinic  at  the  Manhattan  State  Hospital, 
West,  Wards  Island.  We  applied  several  va- 
rieties of  plaster  simultaneously  to  the  same 
patient,  and  found  that  the  moleskin  plaster 
caused  the  least  irritation ;  in  fact,  when  prop- 
erly applied,  practically  none.  It  is  a  fact, 
however,  that  different  people  have  skins  of 
widely  differing  irritabilit}^,  and  some  so  much 
so  as  to  prove  a  distinct  idiosyncrasy  upon  the 
application  of  any  occlusive  dressing.  The 
oxide  of  zinc  is  an  ingredient  to  allay,  if  not 
entirely  to  prevent,  dermal  irritation. 

In  the  physiological  laboratory  we  have 
learned  of  the  effect  of  varnish  applied  to  the 
bare  skin  of  animals,  namely,  arrest  of  secre- 
tion. The  same  effect  is  produced  with  the 
[171] 


ATONIA   GASTRICA 


pliant  moleskin,  adapting  itself  to  every  curve 
and  movement  of  the  muscles,  not  separating 
from  the  surface  at  various  points,  as  do  other 
varieties  of  plasters.  There  is  no  irritation  to 
be  feared  so  long  as  the  well-sticking,  properly 
applied  rubber  plaster  on  moleskin  excludes  ac- 
cess of  air.  Occasionally  at  the  margins,  or  at 
some  point  that  has  inadvertently  become  loos- 
ened, there  may  happen  irritation  due  to  allow- 
ing access  of  air,  permitting  secretion  from  the 
sweat-glands.  This  occurrence  has  been  men- 
tioned already  in  a  foregoing  chapter. 

The  German  writers  have  called  attention  to 
the  advisability  of  previously  cleansing  the  ab- 
dominal surface  with  ether  before  applying  the 
plaster  and  to  shave  where  it  is  necessary.  All 
this  is  needed  to  prevent  irritation,  to  secure 
asepsia,  besides  for  another  reason.  In  order 
to  secure  and  maintain  the  greatest  possible  de- 
gree of  adhesion,  it  is  indispensable  to  see  that 
the  skin  is  perfectly  dry,  free  from  oily  or 
greasy  substances,  or  from  any  sort  of  dusting 
powder. 

A  number  of  experiments  were  made  with  the 
[172] 


PLASTER  FOR  ABDOMINAL  BELT 

various  moleskin  plasters  manufactured  by  sev- 
eral makers,  and  of  these  I  make  the  following 
criticism :  Several  of  them  were  somewhat  stiff 
and  did  not  adapt  themselves  well  to  the  body 
curves ;  some  did  not  stick  well,  the  plaster 
mass  being  too  dry;  some  did  not  retain  the  ad- 
hesive qualities  long  enough.  Johnson  &  John- 
son's gave  us  the  best  satisfaction.  It  is 
soft,  pliable,  sticks  well.  One  patient  of  mine 
has  worn  a  Rose's  belt,  rubber  adhesive  plaster 
on  moleskin,  made  by  this  firm,  for  over  five 
months  without  any  appreciable  irritation. 
Once  in  four  weeks  the  belt  was  removed,  the 
abdominal  surface  cleansed,  and  then  a  fresh 
belt  applied. 

According  to  our  experience,  the  oxide-of- 
zinc  rubber  plaster  on  moleskin,  what  is  known 
in  the  trade  as  "  Z  O "  plaster,  is  the  ideal 
material.  The  plaster  comes  in  rolls  of  one 
and  of  five  yards  and  seven  inches  in  width. 

The  ultimate  success  depends  largely  on  the 
employment  of  the  best  type  of  plaster. 


[173] 


VI 

HISTORY    AND    LITERATURE 

On  the  basis  of  literature  R.  Weissmann,  of 
Lindenfels,  Germany,  gave  in  a  monograph, 
"  Ueber  Enteroptosie — Magen-  und  Darmato- 
nie, " — a  historical  sketch  on  the  study  of  atonia 
gastrica,  of  which  I  avail  myself  to  a  great  ex- 
tent. In  fact,  this  whole  chapter  is  a  transla- 
tion of  some  part  of  Weissmann's  treatise. 

As  far  back  as  1887  Lindner  wrote  that  minor 
gynecological  affections  were  receiving  the 
strictest  attention,  while  gastric  atony  was  per- 
sistently overlooked.  Volland,  in  1896,  also 
dwelt  upon  the  eminently  practical  importance 
of  the  doctrine  of  ventral  atony  and  enterop- 
tosia,  and  considered  it  his  duty  to  draw  the  at- 
tention of  every  practitioner  to  these  ailments. 
He  is  convinced  that  the  recognition  and  cor- 
rect interpretation  of  these  conditions  will  pave 
the  way  to  regaining  the  confidence  of  a  large 
[174] 


HISTORY  AND   LITERATURE 

percentage  of  the  sufferers  of  the  better  class, 
now  alienated  from  the  medical  profession. 
For  we  might  as  well  candidly  acknowledge 
that  we  have  not  accorded  proper  recognition 
to  these  conditions  and  their  sequels,  much  less 
have  we  treated  them  successfully.  As  far  as 
VoUand  has  been  able  to  observe,  the  vast  ma- 
jority of  so-called  neurasthenics  were  suffering 
from  gastric  disorders  due  to  gastroptosia.  He 
feels  sure  that  the  most  effective  point  of  attack 
against  neurasthenia  is  unquestionably  the  pre- 
viously affected  stomach  and  intestines. 

The  kidney  was  the  first  of  the  abdominal 
viscera  to  be  recognized  in  connection  with 
dislocation.  Floating  kidney  was  first  accu- 
rately described  by  Bayer  in  184 1.  As  causes 
for  the  development  of  floating  kidney,  this 
author  specified  tight-lacing,  indirect  pressure 
by  the  liver,  loss  of  adipose  tissue,  menstrua- 
tion, pregnancy,  effects  of  abdominal  pressure 
in  hard  labor,  concussion  in  dancing  and  riding, 
traumatic  causes. 

Hertzka,  writing  thirty-five  years  later  and 
differentiating  between  fixedly  dislocated  and 
[175] 


ATONIA  GASTRICA 


floatingly  dislocated  kidney,  gave  as  the  etiolog- 
ical factor  all  conditions  increasing  abdominal 
pressure  for  more  or  less  protracted  periods — 
such  as  pregnancy,  chronic  obstruction,  liver 
hyperemia,  long-sustained  abdominal  colics 
with  persistent  vomiting,  and,  finally,  the  ef- 
fects of  a  sudden  blow  or  fall. 

Landau  looked  upon  disappearance  of  kidney 
fat  and  relaxation  of  the  abdominal  walls,  with 
diastasis  of  the  recti  muscles,  as  the  dominant 
etiological  factors. 

Lindner  adds  to  the  etiology  of  floating  kid- 
ney in  women  the  fact  that  it  does  not  only 
occur  in  muciparous  women  with  relaxed  ab- 
dominal walls,  but  in  larger  percentage  in  those 
who  have  borne  no  children.  Coincidence  of 
floating  kidney  with  malpositions  in  the  genital 
organs  was  noted,  but  only  in  patients  with  re- 
laxation of  the  abdominal  walls,  Lindner  says 
that  the  misplacement  of  genital  organs  is 
not  the  cause  of  floating  kidney,  as  affirmed  by 
Landau  and  Senator,  nor  yet  the  loss  of  renal 
adipose  tissue,  nor  was  he  able  to  agree  with  v. 
Fischer  Benzon  as  to  the  causal  effect  of  tight- 
[176] 


HISTORY  AND   LITERATURE 

lacing  and  corsets.  Indeed,  a  rationally  con- 
structed corset  hinders  prolapse,  and  the  skirt 
supports  are  tightened  below  the  edge  of  the 
liver.  He  maintains  that  inborn  anomalies,  or 
at  least  a  congenital  disposition,  are  a  true  cause. 
This  opinion  is  repeated  by  several  authors  of  a 
later  period.  Krez  looks  upon  innate  disposi- 
tion to  relaxation  of  abdominal  supports  as  a 
prime  factor. 

Becker  and  Lennhoff  established  certain  rela- 
tions between  the  lay  of  the  kidneys  and  the 
form  of  the  body,  and  detail  this  by  stating  that 
the  right  kidney  is  most  often  palpable  in  the 
slender  with  pleasing  bodily  outlines,  long,  nar- 
row thorax,  and  slightly  flattened  abdomen. 
The  peculiarity  of  this  bodily  shape  might  be 
expressed  in  the  index : 

^^i^xiood.h. 

c  .  a 

in  a  fraction  to  be  multiplied  by  lOO,  the  nu- 
merator of  which,  expressed  in  centimeters, 
represents  the  distance  between  the  jugular 
fossa  and  the  symphysis  pubis,  and  the  denom- 
inator of  which  represents  the  minimum  cir- 
cumference of  the  abdomen.  The  greater  the 
12  [177] 


ATONIA   GASTRICA 


index,  the  more  probable  the  chance  of  palpa- 
ting the  kidney.  An  index  of  above  "JJ  made 
it  safe  to  figure  on  palpable  kidney  in  (German) 
women. 

Two  kinds  of  enteroptosia  are  discerned  by 
Frickhinger,  namely,  the  acquired  and  the  he- 
reditary, the  latter  to  be  found  in  connection 
with  kyphosis  and  paralytic  thorax.  Stiller 
likewise  acknowledges  that  enteroptosia  may 
be  acquired.  In  the  absence  of  an  enteroptotic 
habitus,  the  absence  of  the  tenth  floating  rib 
furnishes  the  point. 

The  sum-total  of  enteroptosia  is  claimed  by 
Glenard  to  be  based  upon  a  vitumi  primes  for- 
viationis.  Corsets,  lacings,  parturition,  high 
heels,  acute  or  chronic  traumata  are  merely 
chance  causes.  The  most  important  contribu- 
ting cause  is  the  disappearance  of  adipose  tis- 
sue. That  the  condition  in  toto  of  enteroptosia 
is  the  result  of  an  inherited  tendency  is  proven 
by  a  hereditary  manifestation — the  above-men- 
tioned tenth  floating  rib.  Bouveret,  Charcot, 
Ewald,  Drummond,  and  Kuttner  pronounce  in 
favor  of  hereditary  tendency.  The  same  view- 
[178] 


HISTORY  AND  LITERATURE 

point  is  supported  by  Obrastzow.  He  states 
that  the  frequent  coincidence  of  neurasthenia 
and  enteroptosia  is  to  be  explained  by  the  fact 
that  in  true  enteroptosia,  apart  from  prolapse  of 
the  abdominal  viscera  and  defective  general  nu- 
trition, constitutional  defects  of  innervation  of 
the  abdominal  muscles  work  hand-in-hand  with 
a  (probably  hereditary)  defective  muscular  struct- 
ure. It  can  not  properly  be  surmised  that 
hereditary  enteroptosia  occurs.  Its  full  develop- 
ment is  attained  only  at  the  age  of  puberty. 
Hereditary  taint  plays  an  important  part  in 
its  causation,  and  he  considers  enteroptosia  a 
symptom  of  degeneration. 

Strauss  recognizes  two  groups  in  gastropto- 
sia.  In  the  first,  gastroptosia  represents  an 
anomaly  of  the  physical  constitution.  In  the 
second,  it  presents  a  disorder  called  forth  by 
local,  and  for  the  most  part  mechanical,  causes. 
In  the  first  group  the  troubles  are  a  localized 
manifestation  of  a  more  or  less  lowered  physio- 
logical condition.  In  the  second  group  the 
dislocating  cause  may  be  sought  for  in  the 
stomach  or  outside  of  it.  Those  within  the 
[179] 


ATONIA  GASTRICA 


stomach  are  permanently  abnormal  disturbance 
consequent  upon  motor  insufficiency,  with  or 
without  dilatation,  continuous  hypersecretion 
(as  we  have  seen,  there  are  cases  in  which  defi- 
cient secretion  and  dilatation  are  eo  ipso  always 
present — R.),  and  pyloric  tumors.  Those  out- 
side the  stomach  are  traction  by  hernia,  more 
especially  peritoneal  hernia. 

Chvostek,  who  as  far  back  as  1876  described 
a  case  of  floating  (wandering)  liver,  as  well  as 
Meissner,  is  of  opinion  that  the  cause  thereof 
is  to  be  sought  for  in  hereditary  relation  and 
lengthening  of  the  suspensory  ligament  of  the 
liver. 

That  the  liver  plays  an  important  r61e  in  the 
development  of  nephroptosia  is  also  dwelt  upon 
by  Kuttner,  altho  he  attributes  the  lowering  of 
the  kidney  primarily  to  'adipose-tissue  waste. 
The  respiratory  excursions  of  the  kidneys  grad- 
ually increase,  until  finally  the  kidneys  are  no 
longer  struck  by  the  excursions  of  the  dia- 
phragm. Now  the  liver  transfers  its  respira- 
tory movements  to  the  right  kidney,  pressing  it 

down  still  farther.     This  is   stated  to  be  the 
[180] 


HISTORY  AND   LITERATURE 

reason  why  floating   kidney  occurs    more  fre- 
quently on  the  right  than  on  the  left  side. 

According  to  Meinert,  the  great  majority  of 
enteroptosias  are  caused  by  tight-lacing,  no  m?t- 
ter  whether  effected  by  corsets  or  waist-bands. 
Some  malformations  of  the  thorax  act  in  the 
same  manner. 

The  same  view  is  maintained  by  Kelling, 
save  that  he  admits  that  it  is  the  weight  of  the 
liver  and  the  stomach  that  may  drag  them 
down,  whenever  the  space  within  the  abdomi- 
nal cavity  has  become  too  large  for  its  contents, 
as  after  childbirth,  in  emaciation,  and  the  occur- 
rence of  hernia.  Huber  also  makes  tight-la- 
cing responsible  for  the  origin  of  enteroptosia ; 
likewise  Fleiner,  altho  the  latter  attributes  the 
origin  of  stomach  collapse  to  the  diminution  of 
ventral  space  through  pressure  of  corsets,  with 
consequent  diminution  of  food  supply,  emacia- 
tion, and  vacant  space  into  which  the  stomach 
can  relapse.  Meinert  makes  enteroptosia  de- 
pendent upon  clothing.  Every  dress  worn  by 
young  women  before  the  fifteenth  year,  fast- 
ened to  the  thorax  instead,  as  alone  correct,  of 
[i8i] 


ATONIA  GASTRICA 


the  shoulders,  leads  to  gastroptosia.  Only  the 
pressure  of  a  solid  neighboring  organ,  the  liver, 
is  capable  of  forcing  the  suspensory  support  of 
the  stomach  to  yield.  For  this  reason  neither 
a  primary  weakness  of  the  ligamentary  appara- 
tus (Glenard)  nor  the  relaxation  of  the  anterior 
abdominal  wall  (Schmidt)  is  the  initial  cause  of 
enteroptosia. 

The  statements  of  Meinert  and  Fleiner,  con- 
cerning the  predisposing  of  certain  thorax  forms 
and  of  volume  conditions  within,  as  bearing 
upon  the  development  of  gastroptosia,  are  con- 
firmed by  Bial;  v.  Koranyi  attributes  to  high 
heels,  in  combination  with  the  considerable 
load  of  clothing  fastened  around  the  hips,  the 
responsibility  for  floating  kidney  in  women. 
As  to  corsets,  he  agrees  with  Ebstein  in  accord- 
ing them  a  subsidiary  share  in  the  etiology  of 
floating  kidney.  Stifler  fails  to  find  a  special 
cause  for  the  occurrence  of  floating  kidney  in 
pregnancy  and  childbirth,  inasmuch  as  they 
occur  so  frequently  in  the  non-bearing.  The 
main    cause   is   diminution    of    intraabdominal 

pressure  or  else  strengthening  of  the  same  in  a 

[182] 


HISTORY   AND    LITERATURE 

negative  sense,  as  in  abdominal  fat  accumula- 
tion and  prolapsed  abdomen.  Hufschmidt  lays 
stress  on  diastasis  of  the  recti  muscles,  which 
favors  and  facilitates  the  occurrence  of  enterop- 
tosia.  Under  normal  conditions  the  weight  of 
the  abdominal  organs  and  respiratory  pressure 
influence  abdominal  pressure.  Schwerdt  also 
mentions  diminution  of  abdominal  pressure  as 
the  most  important  symptom  of  enteroptosia, 
and  distinguishes  between  tension  pressure  and 
burden  pressure.  The  initial  point  of  enterop- 
tosia is  relaxation  of  the  anterior  abdominal 
walls  and  consequent  lessening  of  tension  pres- 
sure. The  organs  in  the  abdominal  cavity  are 
forced  to  follow  the  laws  of  gravity  and  to  sag 
down.  Thereupon  the  burden  pressure  in  the 
lower  parts  is  increased.  Increase  of  tension 
pressure,  on  the  other  hand,  begets  decrease  of 
burden  pressure.  Measurements  in  a  variety  of 
bodily  postures  of  the  total  pressure  in  cases  of 
enteroptosia  indicated  a  lower  pressure  than  in 
the  non-afflicted.  Distention  pressure  is  the 
name  given  by  the  author  to  the  tension  pro- 
duced by  gases  forming  in  the  alimentary  canal. 
[183] 


ATONIA   GASTRICA 


Persistent  high  pressure  may  cause  paresis  and 
paralysis  of  the  muscular  coats,  and,  eventually, 
abolition  of  tension  pressure. 

Langerhans  refuses  to  recognize  diminution 
of  intraabdominal  pressure  as  an  etiological 
factor  in  enteroptosia,  and  even  questions  its 
existence.  Concerning  the  etiology  of  enterop- 
tosia he  promulgates  the  following  theses  : 

1.  Relaxation  of  the  abdominal  muscles  gives 
rise  to  the  enteroptosia  of  Landau. 

2.  There  is  such  a  thing  as  a  hereditary  en- 
teroptotic  tendency. 

3.  The  corset  exercises  no  deleterious  effect. 

4.  Genuine  chlorosis  frequently  leads  to  gas- 
troptosia — the  enteroptosia  of  Meinert. 

5.  Nervous  dyspepsia  is  one  of  the  etiologi- 
cal causes  of  enteroptosia.  Nervous  dyspepsia 
exists  with  or  without  enteroptosia. 

According  to  Pick,  the  causation  of  enterop- 
tosia in  a  majority  of  cases  is  to  be  looked  for 
in  a  decrease  of  tonicity  in  the  muscles  of  the 
abdominal  walls.  This  decrease  maybe  caused 
by  general  debility,  lack  of  usage  of  abdominal 
muscles,  adipose-tissue  deposit  in  the  subcuta- 
[184] 


HISTORY  AND   LITERATURE 

neous  connective  tissue,  diastasis  of  the  recti 
muscles.  The  sequence  is  lessening  of  intra- 
abdominal pressure.  This  makes  it  possible 
for  the  intestines  to  yield  to  the  pressure  of 
gases  from  within,  and  thus  atony  of  stomach 
and  bowels  is  generated,  which  condition  favors 
their  sagging. 

According  to  Aufrecht,  nephroptosia  is  the 
beginning,  the  primary  stage,  and  primary  re- 
quirement of  enteroptosia.  Nephroptosia  orig- 
inates either  spontaneously  in  inherent  fiabbi- 
ness  of  ligaments  or  through  pressure  on  the 
part  of  the  liver  consequent  upon  lacing,  etc. 
Displacement  of  the  kidney  leads,  in  conse- 
quence of  its  connection  with  the  duodenum  by 
means  of  the  duodeno-renal  ligament,  to  trac- 
tion of  the  duodenum  and  interference  with  its 
function.  The  influence  upon  the  stomach  by 
the  dragging  duodenum  leads  to  atony.  The 
persistently  downward  gliding  kidney  likewise 
impinges  upon  the  right  curve  of  the  colon  and 
hinders  normal  peristalsis  by  its  volume  no  less 
than  by  traction  exercised  by  the  hepatocolic 
ligaments.  The  consequence  is  stagnation  of 
[185] 


ATONIA   GASTRICA 


the  contents  of  the  ascending  colon — obstipa- 
tion. Thus  a  nephroptosia  alone  may  call  forth 
the  appearances  of  enteroptosia.  Enteroptosia 
is  joined  to  nephroptosia  when  tension  of  the 
abdominal  walls  is  diminished.  Women  who 
have  borne  children  furnish  the  largest  contin- 
gent among  sufferers  from  this  affection. 

Glenard  was  the  first  to  describe  enteroptosia 
as  a  pathological  entity,  as  to  the  etiology. 
The  starting-point  of  enteroptosia,  according  to 
Glenard,  is  in  the  flexure  of  the  ascending 
colon.  This  is  the  first  to  sag,  followed  by  the 
transverse  colon,  this  in  turn  exercising  traction 
on  the  pylorus  and  the  omentum,  thus  causing 
descent  of  the  stomach  and  liver.  The  sagging 
of  the  curve  of  the  ascending  colon  gives  rise 
also  to  traction  on  the  parietal  peritoneum  and 
thus  encourages  sinking  of  the  right  kidney 
downward  and  inward.  Sagging  of  the  flexure 
is  caused  by  trauma,  pressure  upon  the  lower 
part  of  the  thorax  by  the  corset,  by  strain,  re- 
laxation of  the  abdominal  wall,  and  pregnancy. 
Montenius  maintains  that  enteroptosia  is 
brought  about  by  all  conditions  which  interfere 
[i86] 


HISTORY  AND   LITERATURE 

with  the  normal  mutual  pressure  of  the  intes- 
tines. 

Dietl  was  the  first  to  point  out  the  frequent 
occurrence  of  floating  kidney  and  a  definite 
group  of  symptoms  caused  by  the  same.  Chro- 
back  first  demonstrated  the  connection  between 
movable  kidney  and  hysteria.  Hertzka  early 
reported,  with  regard  to  dislocated  kidneys,  that 
the  symptoms  exhibited  by  the  patient  were  so 
manifold  and  divergent  as  to  cause  the  physi- 
cian to  overlook  the  possibility  of  this  disease. 
Accompanying  pain  was  probably  consequent 
upon  traction  upon  the  blood-vessels  and  nerve- 
plexuses. 

According  to  Lindner,  floating  kidney  is  the 
most  frequent  abnormal  condition  of  the  female 
body,  and  this  influence  upon  a  great  percen- 
tage of  diseases  to  be  observed  in  women  is  yet 
not  generally  known  and  properly  estimated. 

The  symptom  symposium  in  palpable  kidney 
is,  according  to  Kuttner,  very  unstable  and  du- 
bious. He  enumerates  pain,  neuralgias,  dizzi- 
ness, fainting  spells,  high-grade  nervousness, 
hysteria,  hypochondria,  heart  palpitation,  and 
[187] 


ATONIA   GASTRICA 


digestive  troubles  as  the  more  frequent  symp- 
toms. Persistent  constipation  also  obtains. 
He  joins  Oser,  Nothnagel,  Leube,  and  Ewald 
in  opining  that  in  the  majority  of  cases  of  gas- 
troectasis  and  mobile  kidney  it  is  a  matter  of 
coincidence. 

The  first  one  to  describe  the  whole  round  of 
symptoms  which  occur  in  enteroptosia  as  a  dis- 
ease sui  generis  was  Glenard.  In  one  of  his 
first  publications  {Reviie  de  Mddecine,  January, 
1887)  he  says:  "Clinical  observation  goes  to 
prove  that  enteroptosia  in  the  same  and  identi- 
cal patient  is  diagnosticated  and  treated  with- 
out favorable  result,  according  to  the  various 
phases  of  this  trouble,  as  anemia,  then  as  metri- 
tis (by  cauterization),  or  as  prolapse  of  the 
uterus  (where  pessaries  come  into  use),  then  as 
dyspepsia,  then  as  rheumatism,  still  further  on 
as  gall-stone  colic,  then  as  masked  carcinoma, 
still  later  as  a  neurosis,  as  hypochondria,  as 
hysteria,  and,  finally,  as  neurasthenia.  At 
length  the  physician  must  make  way  for  the 
quack,  unless  the  patient  prefers  to  forego  all 

treatment." 

[iSS] 


HISTORY  AND   LITERATURE 

Ewald,  the  first  in  Germany  to  describe  Gle- 
nard's  disease,  questions  whether  enteroptosia 
occurs  as  frequently  as  Glenard  affirms,  and 
holds  the  diagnostic  points  of  Glenard  as  not 
convincing.  The  transverse  cord,  mentioned 
above,  is  the  pancreas;  pulsation  of  the  aorta 
common  to  many  conditions.  Nephroptosia 
does  not  necessarily  carry  splanchnoptosia  in 
its  train.  The  author  differentiates  the  picture 
of  splanchnoptosia  from  that  of  pendent  abdo- 
men (Landau).  Traction  of  ligaments  causes 
disturbances  by  reflex  action,  culminating  in 
insufficient  action  upon  gastric  and  intestinal 
contents,  various  stagnations,  accumulation  of 
decomposition  products  of  albuminous  bodies 
and  the  metabolic  products  of  microbes,  this 
leading  up  to  autointoxication. 

According  to  Meinert,  at  least  ninety  per 
cent,  of  floating  kidneys  are  concomitants  of 
enteroptosia.  This  accounts  for  the  multipli- 
city of  subjective  complaints. 

Frickhinger  attaches  secondary  importance 
only  to  the  symptoms  described  by  Glenard, 
and  sums  them  up  as  indications  of  neuras- 
[189] 


Atonia  gastrica 


thenia  and  hysteria.  Manifestations  character- 
istic of  enteroptosia,  as  described  by  Glenard 
and  Fereol,  are  merely  sequences  of  organic 
disturbances,  analogous  to  those  occurring  in 
other  diseases.  As  the  pathological  processes 
relate  largely  to  the  alimentary  canal,  it  is  ex- 
plainable why  it  so  frequently  presents  itself  in 
the  guise  of  nervous  dyspepsia.  Enteroptosia 
is  not  a  clearly  defined  pathological  entity  by 
any  means. 

Boas  finds  it  difficult  to  exclude  evidence  of 
a  functional  neurosis.  On  the  other  hand,  the 
organic  basis  of  Ewald's  "  nervous  dyspepsia  " 
could  not  be  gainsaid. 

Kelling  finds  the  clinical  importance  of  gas- 
troptosia  in  the  increasingly  difficult  work  of 
the  stomach  through  increase  in  the  Hiibho- 
he  (Oser).  (The  translation  is  "  lift  height," 
but  I  do  not  know  what  it  means.  —  R.) 
Furthermore,  that  food  in  its  onward  prog- 
ress through  the  duodenum  has  to  be  pushed 
forward  in  a  tube  bent  in  an  acute  angle.  The 
revulsion  and  churning  up  of  contents  is  car- 
ried on  by  a  stomach,  previously  resting  on 
[190] 


HISTORY  AND   LITERATURE 

proper  support,  but  now  in  a  sagging  condition, 
whereby  the  muscles  are  subjected  to  consider- 
able tension  by  the  weight  of  the  contents.  And 
since  the  muscular  coat  suffers  from  overdisten- 
tion,  the  stomach  is  incapable  of  exercising  the 
pressure  required  for  proper  digestion.  It  fol- 
lows that  the  physiological  capacity  of  the  stom- 
ach in  gastroptosia  is  far  from  normal.  Agreeing 
with  Meinert,  Kelling  brings  anemia  into  rela- 
tion with  enteroptosia.  Succussion  sounds  are 
of  frequent  occurrence  in  gastroptosia. 

Briiggemann  denies  the  connection  between 
gastroptosia  and  chloriasis.  True,  he  always 
found  abnormal  sagging  of  the  lower  border  of 
the  stomach,  but  claims  this  to  be  caused  by 
atony  of  the  ventricular  walls,  as  a  consequence 
of  changes  in  blood  conditions.  Meltzing  also 
denies  any  connection  between  gastroptosia  and 
chloriasis, 

Fleiner,  and  notably  Stiller,  describe  the 
group  of  symptoms  along  the  lines  of  Glenard. 
Stiller  declares  floating  kidney  to  be  a  local 
manifestation  of  a  general  condition.  He  notes 
how  the  doctrine  of  floating  kidney  has  passed 
[191] 


ATONIA  GASTRICA 


through  considerable  changes  in  the  course  of 
years.  At  the  very  beginning  the  numerous 
dyspeptic  and  nervous  complaints  accompanying 
floating  kidney  attracted  attention.  The  fre- 
quent coincidence  of  dilated  stomach  and  float- 
ing kidney  did  not  pass  unobserved,  before  Gle- 
nard  formulated  the  conception  of  enteroptosia. 
This  indicated  a  marked  advance  in  the  domain 
of  neurasthenia  and  nervous  dyspepsia.  To 
him  they  were  familiar  pictures,  these  grace- 
fully built,  lean,  pale  young  men  and  women 
with  dyspeptic  and  nervous  complaints — one  is 
almost  tempted  to  say  with  nervous  facial  ex- 
pression— presenting  on  examination  thin,  soft 
abdominal  walls,  a  flabby,  splashing  stomach, 
and  a  palpable  kidney,  mostly  on  the  right, 
sometimes  on  both  sides.  Landau  declares 
retroflexion  of  a  movable  uterus  to  be  one  of  the 
symptoms  of  enteroptosia.  According  to  Ag6- 
ron,  pronounced  gastroenteroptosia  may  have 
in  its  wake  far-reaching  disturbances  of  nutri- 
tion, under  the  guise  of  anemia  or  chloriasis, 
caused  by  high-grade  motory  disturbances  of 
the  sunken  stomach. 

[192] 


HISTORY  AND   LITERATURE 

Leo  disputes  the  causal  relation  between  gas- 
troptosia  and  chloriasis.  Like  Briiggemann, 
he  acknowledges  that  the  lower  margin  of  the 
stomach  sags  to  abnormal  depth  in  chloriasis; 
this  in  consequence  of  atony,  not  of  gastropto- 
sia.*  It  is  true  that  in  the  chlorotic  who  have 
worn  a  corset  gastroptosia  is  demonstrable,  but 
chloriasis  is  by  no  means  rare  in  young  women 
who  have  never  worn  a  corset.  Owing  to  the 
widespread  use  of  the  corset,  stomach  sagging 
is  an  almost  habitual  abnormality  of  the  female 
sex,  only  a  fraction  of  whom  ever  suffer  from 
chloriasis. 

Bial,  according  to  whom  gastroptosia  in  men 
is  anything  but  a  rare  occurrence,  on  close  ex- 
amination finds  conditions  everywhere  sufficient 
to  explain  the  occurrence  of  anomalies,  without 
having  recourse  to  the  effects  of  simultaneous 
changes  of  position.  That  an  anomaly  of  so 
little  moment  in  the  case  of  men  should  be  of 
such  far-reaching  consequence  in  women  is 
peculiar,  to   say  the  least.     Perhaps   the  cause 

*Bruggemann's  distinction  between  atonia  and  gas- 
troptosia is  incomprehensible. 

13  [193] 


ATONIA   GASTRICA 


should  be  looked  for  in  a  lessened  power  of  re- 
sistance of  the  female  nervous  system. 

Schwerdt,  in  an  extraordinarily  interesting 
essay,  sets  forth  the  view  that  the  designation 
enteroptosia  is  merely  a  symptomatic  designa- 
tion of  the  actual  disorder.  Ptosis  of  the  intes- 
tines by  no  means  plays  the  leading  part.  The 
essence  of  enteroptosia  consists  in  relaxation  of 
the  whole  nervous  system,  a  chronic  condition 
of  fatigue  which,  in  whatever  way  we  look  at 
it,  is  a  functional  disease — a  functional  neuro- 
sis— not  only  involving  motor  spheres,  but  like- 
wise sensory  and  negative  territory.  To  the 
disturbances  primarily  evolved  in  the  nervous 
system  must  be  added  those  resulting  from 
autointoxication.  It  results  also  in  functional 
paralysis  of  the  skin,  which  in  enteroptosia 
performs  increased  vicarious,  compensating 
labor. 

This  author  differentiates  three  stages  of  dis- 
ease, which  he  describes  as  follows : 

First  stage :  Progressive  muscular  weakness, 
manifold  sensations,  emaciation,  anemia.  The 
only  objectively  demonstrable  feature  is  loss  of 
[194] 


HISTORY  AND    LITERATURE 

weight,  possibly  decrease  of  physical  energy 
and  of  intraabdominal  pressure. 

Second  stage  :  Completed  condition  of  enter- 
optosia,  one  or  more  abdominal  organs  in  the 
wrong  place,  neuroses  of  the  digestive  appara- 
tus, high-grade  autointoxication. 

By  means  of  compensation  the  disease  in  its 
first  and  second  stages  may  come  to  a  standstill. 
Such  compensations  are  hypertrophy  of  the 
muscular  element  in  the  digestive  tubes  and 
other  hollow  muscles,  coupled  with  increased 
activity  in  the  glands  of  the  skin.  Overfilling 
of  the  organ»ism  with  toxic  material,  general  col- 
lapse  of  physical  powers. 

Schwerdt  opines  that  Basedow's  disease  and 
enteroptosia  are  in  some  manner  intimately 
connected,  and  that  in  the  finality  myxedema 
and  sclerodermia  are  progressive  stages  of  the 
same  disease.  He  pleads  guilty  to  the  use  of 
the  term  "dyscrasia"  throughout  his  disserta- 
tion, and  is  reminded  of  the  armory  of  our  fore- 
fathers, wherein,  together  with  cathartics, 
emetics,  and  diaphoretics,  bleeding  is  put  to 
rest.  Chloriasis  and  anemia,  occurring  as 
[195] 


ATONIA   GASTRICA 


symptoms  of  enteroptosia,  are  declared  by  Bux- 
baum  to  be  due  to  unequal  distribution  of 
blood  and  disturbances  of  circulation  conse- 
quent upon  changed  mechanical  conditions. 
Uneven  blood  distribution,  notably  collection 
and  stagnation  of  blood  in  the  vessels  of  the 
lower  abdomen — capable  of  holding  two-thirds 
of  the  total  quantity — is  apt  to  simulate  high- 
grade  anemia  and  chlorotic  conditions.  Enter- 
optosia is  founded  on  passive  hyperemia,  for 
which  feeble  peristalsis  is  in  part  to  be  held 
responsible;  secondarily,  the  blood  accumula- 
tion is  seconded  by  relaxation  of  the  abdominal 
walls  and  by  the  flow  in  the  intestine. 

According  to  Obrastzow,  temporary  enterop- 
tosia after  advanced  emaciation  does  not  call 
forth  manifestations  of  nervous  dyspepsia,  in 
contradistinction  to  constitutional  "  genuine  " 
enteroptosia.  Langerhans  looks  upon  enterop- 
tosia as  the  most  frequent  cause  of  intestinal 
neurasthenia  and  hysteria.  A  frequent  con- 
comitant is  probably  coloptosis  and,  in  numer- 
ous cases,  retroflexion  of  the  uterus.  Strauss 
(who,  as  noted  above,  distinguishes  two  groups 
[196] 


HISTORY  AND   LITERATURE 

of  gastroptosia)  describes  the  symptoms  of  the 
first  group  precisely  as  does  Stiller.  The  dis- 
ease is  declared  to  be  a  part  symptom  of  a  more 
or  less  pronounced  low  vitality.  Chloriasis  is 
to  him  the  expression  of  a  constitutional  anom- 
aly, which  has  prepared  simultaneously  chlori- 
asis and  the  conditions  for  descent  of  the  stom- 
ach. Chloriasis  may  also  be  responsible  for 
relaxation  of  suspensory  ligaments,  and  thus 
promote  the  occurrence  of  gastroptosia.  That 
in  cases  wherein  gastroptosia  and  neurasthenia 
occur  together  the  latter  is  due  to  the  former, 
is  acknowledged  by  this  author  in  a  limited 
sense  only.  The  disturbances  of  the  stomach 
do  not  follow  a  regular  course,  and  long-persist- 
ing, severe  disturbances  of  motility  are  rare. 

As  symptoms  of  enteroptosia  Krellreuther 
enumerates  the  following :  general,  chronic  de- 
bility; downward  pressure;  exhaustion;  dizzi- 
ness ;  heavy  head ;  fainting  spells ;  lumbar 
pain ;  disturbance  in  the  whole  abdomen ;  pain 
in  one  or  both  hypochondriac  regions;  dysp- 
nea; head  flushes.  In  the  alimentary  canal 
itself:  anorexia;  a  feeling  of  gastric  insuffi- 
[197] 


ATONIA   GASTRICA 


ciency ;  easily  appeased  appetite ;  feeling  of 
fulness  ;  heaviness  and  pressure  on  the  stomach 
(more  particularly  after  eating);  tendency  to 
vomit;  morning  sickness;  frequently  vomiting 
after  meals,  combined  with  eructation ;  heart- 
burn ;  gases  and  splashing  sounds  in  the  stom- 
ach;  pressure-point  in  the  sunken  epigastrium; 
finally  obstipation,  frequently  dominating  the 
whole  picture  of  disease. 

A  vast  majority  of  authors  pronounce  in  fa- 
vor of  abdominal  bandages  (abdominal  support) 
for  the  treatment  of  enteroptosia.  Gunzburg, 
on  the  contrary,  recommends  small  doses  of 
yeast,  calculated  to  promote  improved  nutrition 
and  accumulation  of  adipose  tissue.  Rumpf 
also  questions  the  beneficial  effect  of  bandages, 
and  puts  in  a  plea  for  gymnastics  and  massage. 
In  mobile  kidney  he  claims  to  have  achieved 
sixty  per  cent,  of  cures  and  twenty  per  cent,  of 
improvement  by  the  use  of  Thure  Brandt's  sub- 
nephritic  vibratory  massage.  Stiller,  on  the 
other  hand,  looks  upon  massage  as  essentially 
useless.  Meinert  insists  upon  primarily  ban- 
ishing the  corset,  followed  by  an  endeavor  to 
[198] 


HISTORY   AND    LITERATURE 

reestablish  normal  diaphragmatic  breathing, 
and,  further,  recommends  bran  bread,  lavage  of 
the  stomach,  faradization,  rest,  and  forced  feed- 
ing. The  same  treatment  is  indorsed  by 
Fleiner  and  Pick.  Both  aim  at  removing  the 
weakened  condition  of  the  abdominal  walls  and 
the  raising  of  intraabdominal  pressure.  Bux- 
baum  assumes,  as  already  mentioned  above, 
that  in  enteroptosia  we  are  dealing  with  a  pas- 
sive hyperemia  of  the  lower  abdominal  organs, 
and,  therefore,  therapy  should  consist  in  the 
use  of  such  thermic,  mechanical  (hydrothera- 
peutic),  and  electric  methods  of  treatment  as 
strengthen  the  gut,  intensify  peristalsis,  and 
make  for  intraorganic  acceleration  of  the  blood 
current.  As  one  of  the  first  to  recommend  ab- 
dominal bandages  for  sagging  of  viscera,  Chvo- 
stek  is  to  be  named.  He  uses  an  elastic  belly 
bandage  for  wandering  liver,  compressing  the 
meso-  and  hypogastric  region.  Lindner,  Kutt- 
.ner,  Ewald,  Stifler,  Krez,  Hufschmidt,  Boas, 
Kelling,  Huber,  Schwerdt,  Obrastzow,  Strauss, 
Ostertag,  Maillart,  and  Krellreuther  pronounce 
without  exception  in  favor  of  the  use  of  a  suit- 
[1993 


ATONIA   GASTRICA 


able  belly  bandage.  Evvald  dwells  upon  the 
importance  of  emptying  the  bowels  by  saline 
aperients.  Stifler  adds  the  use  of  carbonated 
steel  baths,  and  claims  to  have  had  success  in 
one  case  by  electrolytic  treatment. 

In  addition  to  bandages  and  belts,  Huf- 
schmidt  recommends  massage,  faradization, 
gymnastics,  and  hydrotherapeutics  (in  this  he 
is  supported  by  Boas),  and  favors  also  forced 
feeding;  he  is  indorsed  by  Kelling,  Strauss, 
and  Kellreuther.  The  latter  condemns  the  pad 
in  floating  kidney,  and  dwells  upon  the  fact 
that  prime  importance  attaches  to  the  actual 
lifting  of  the  pendent  abdomen  by  the  belly 
bandage.  Ostertag,  in  the  construction  of  his 
belly  bandage,  lays  stress  upon  the  bandage 
efficaciously  raising  the  sagging  lower  abdomen 
and  keeping  it  firmly  and  continuously  fixed,  so 
as  to  hinder  any  descent  of  the  parts.  He  aims 
to  accomplish  this  by  giving  support  by  the 
bandage  to  the  bony  structures,  both  above 
and  below.  Langerhans  favors  the  abdominal 
bandage  only  in  the    so-called    Landau    cases, 

and  for  the  rest  recommends  gymnastics.     At 

[200] 


HISTORY  AND   LITERATURE 

all  times  the  nervous  system  is  entitled  to  the 
strictest  observation  and  treatment.  Aufrecht 
recommends  Gl^nard's  hypogastric  belt.  By 
means  of  this  belt  a  diminution  of  abdominal 
space  in  an  upward  and  downward  direction  is 
produced.  This  causes  limitation  of  mobility  in 
descended  organs,  checks  their  to-and-fro  move- 
ments, and  lessens  the  stretching  of  suspensory 
ligaments,  notably  those  of  the  kidney  and  stom- 
ach. Thus  circulatory  conditions  are  vastly 
improved  and  the  nervous  reflexes  caused  by 
ligamentary  traction  are  obviated.  Glenard's 
belt  is  not  a  belly  bandage  in  the  properly  ac- 
cepted sense  of  that  term.  All  so-called  abdom- 
inal bandages  are,  according  to  Aufrecht,  abso- 
lutely worthless  in  the  treatment  of  gastroptosia. 
In  his  essay  of  1896  Schwerdt  defines  the 
aims  of  therapy  in  enteroptosia :  the  raising  of 
intraabdominal  tension  pressure,  the  lessening 
of  contact  pressure,  and  removal  of  gaseous 
distention  pressure.  Accordingly,  the  therapy 
seems  to  suggest  massage,  gymnastic  exercises, 
belly  bandages,  regulation  of  the  bowels,  inter- 
diction of  fattening  diet,  and  employment  of 
[201] 


ATONIA   GASTRICA 


disinfectants  for  abnormal  fermentative  proc- 
esses. In  his  next  publication,  in  1897,  the 
same  author  dwells  upon  the  value  of  hydro- 
pathic methods  for  antagonizing  autointoxica- 
tions. Liberal  diet,  massage  of  the  whole 
body,  and  more  particularly  of  the  perineum, 
were  strongly  recommended.  For  strengthen- 
ing the  abdominal  muscles  he  recommends 
gymnastic  exercises,  to  be  carried  on  at  first  in 
the  dorsal  position.  Where  causal  treatment 
of  relaxation  of  the  abdominal  muscles  and  its 
sequels  by  mechano-  and  electrotherapy  was 
not  feasible,  the  application  of  a  belly  bandage 
afforded  relief,  notably  in  splanchnoptosia  with 
pendent  abdomen.  Schwerdt  says  that  perhaps 
blood-letting  might  be  of  service  in  combating 
the  dyscrasia  incidental  to  enteroptosia. 

J.  Ross  Watt  communicates  a  peculiar  meth- 
od of  treating  floating  kidney,  invented  by  him- 
self, based  upon  the  assumption  that  the  wear- 
ing of  abdominal  bandages,  as  also  the  formerly 
frequent  surgical  interference,  had  not  been 
productive  of  satisfactory  results.  He  cuts 
two  wing-shaped  pieces  from  ordinary  packing 
[202] 


HISTORY  AND   LITERATURE 

paper,  which  are  to  cover  the  whole  of  the 
lower  abdomen,  to  meet  in  the  median  line  and 
on  all  sides  project  two  centimeters  above  the 
bony  borders.  From  this  model  two  leaden 
wings  are  manufactured,  covered  with  cloth  and 
placed  upon  the  patient's  abdomen  and  every- 
where firmly  adjusted  by  the  hand,  after  bringing 
the  kidney  to  its  normal  condition.  To  a  long, 
well-fitting  corset,  drawn  over  these  leaden 
wings,  these  wings  are  fastened.  Adjustment 
and  removal  of  this  bandage  are  to  be  done  in  the 
recumbent  position.  The  flexible  lead  readily 
assumes  the  shape  of  the  abdominal  surface,  and 
thus  exercises  equable  pressure  upon  the  whole 
surface  of  that  part  of  the  body.  Hence  the 
weight  is  not  greatly  felt.  The  author  claims  to 
have  achieved  permanent  fixation  of  the  kidney 
to  its  normal  site  inside  of  three  or  four  months. 
Rose,  Rosewater,  and  Schmitz  stand  for  the 
principle  that  imperfect  activity  of  the  abdomi- 
nal muscles  is  to  be  compensated  by  adhesive 
plaster,  and  each  one  of  the  three  authors 
named  endeavored  in  his  own  manner  to  make 
practical  application  of  this  principle. 
[203:] 


